- Aug 17, 2007
- Attending Physician
I get a number of PM's regarding subacute/SNF rehab. There are a lot of misconceptions regarding the role physiatrists have in this practice setting. Working in the subacute setting was highly discouraged by my program director during residency even though quite a few of our attending had subacute side gigs. Unfortunately even now most residents do not get exposure during training. I wanted to make myself available to hopefully answer any questions people might have.
- What is subacute/ SNF rehab?
Over the past decade and more intensely over the past 7 years, there has been a steady decline of patients being approved for Inpatient Rehab Facility (IRF) stays by Medicare. Through payer regulatory changes and certain determinations, these patients who would have been approved for IRF stays are now being discharged to Skilled Nursing Facilities (SNF). As of 2014, there were 339,000 beneficiaries in IRF vs 1.7 million in SNFs. Rehabilitation in the SNF environment is rapidly emerging as the predominant level of post-acute rehabilitation care in the United States. More patients will receive their rehabilitation in a SNF today than in an IRF—and the trend is likely to continue! Physiatrists have worked in the subacute environment since the 80’s but our involvement in this level of care is now more important than ever.
- Why did you decide to work in this setting?
I was fortunate enough to complete my residency at a hospital with an attached SNF unit. As residents, we rounded on patients and covered them during call. The hospital also had a dedicated subacute rotation where residents spent time with the Attending Physicians learning firsthand how to provide care for patients in this setting. Most of our teaching attendings balanced an acute, SNF, and outpatient practice. Initially my interests were aligned within sports medicine, however, I quickly realized that a more balanced practice going forward would be the best answer.
- How is it different from acute rehab and outpatient?
In a subacute setting, I work as a consultant in a team model where a primary care physician and I co-manage patient care. The types of patients can vary depending on the facility but most often I provide rehab and pain management for patients undergoing therapy. Patient mix is approximately 30-40% orthopedic, 15-20% neuro and the rest are cancer and cardiopulmonary rehab patients. The vast majority of issues I am managing are ‘bread and butter’ rehab including spasticity, pain, bowel/bladder, neuropathy, and amputee care, etc. I will also occasionally perform bedside joint injections. The primary care physician manages all other medical issues and will take call.
- How often are the patients seen?
As per the AAPM&R position statement on a physiatrist’s role in skilled nursing facility, “in the ideal situation, a physiatrist in a SNF setting will serve in a consulting or co-treating physician role and visit the patient two to three times a week depending on the needs of the patient” (June 2016). As the length of stays are declining, sometimes the frequency increases to 3 times a week with the goal of leading to greater functional gains by the patient and cost saving to the health care system.
- What is the typical work schedule?
I work 4 days a week about 8 hours a day. In my capacity as a consultant, I do not work on weekends or take call. Typically, I am able to see approximately twenty follow-up and five new patients a day. I also have an outpatient sports/spine practice one day a week and a medical legal practice.
- How did you start your practice?
I had the opportunity to start the practice myself but I was concerned with stability and future Medicare regulations. I ended up joining a company as an independent contractor. The company provides managerial services for my practice. Initially one of my main concerns was stability but given that my overhead is very low, I am able to take home most of what I earn and have tremendous flexibility to create a work-life balance. I have the ability to create my own schedule, as well as implement changes and improvements to my practice and routine as needed. This type of work can be done on a full-time basis or as an addition to your current form of practice.
- What is the future of SNF rehab and is this a practice setting you feel is sustainable into the near future?
The medical landscape has changed drastically since I began practicing in the SNF rehab setting 7 years ago. The changes in effect have led to increased focus on providing quality care, reducing readmissions to the hospitals and reducing cost. Physiatrists are well positioned as the ideal specialists to facilitate these objectives by providing continuing care of the patients during various stages of recovery.
- Do you find the work rewarding? I am extremely fortunate to work in the SNF rehab space. I believe I make a difference in the lives of my patients every day. I have the opportunity to provide outcome-oriented care, lead a team, and assist with cost saving while continuing to strive for optimal patient care. I am able to set goals, which correspond with the patient and their family’s needs. My focus is on eliminating barriers that impede transition from facility to home or a more home-like environment. I am also able to practice general physiatry without the pressures that come along with being an employee in a large scale medical practice or hospital.