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 A Look At New LTC Physician Models

Providers say the time is ripe to reconsider how docs work in long term care.

 

Changes to long term care are coming at a rapid-fire pace—accountable care organizations, health care reform, person-centered care, and medical homes. In response to these changes and in preparation for an unpredictable future, organizations increasingly are seeking ways to ensure successful care transitions, streamline communication, increase cost effectiveness, and improve outcomes.
 
Toward this end, there is a trend of increasing the physician presence both at the corporate and facility levels. Today, a physician as an employee is not an alien concept in long term care. In fact, it is becoming a way of life.

Responding To Change—Proactively

So what is driving this trend toward physician employees? “Health care reform will call for us to go from a volume-based to a value-based system,” says James Avery, MD, chief medical officer of Golden Living, Plano, Texas.
 
“Health care organizations, hospitals, or nursing homes will be judged by the value of care patients receive,” he notes.
 
As one thinks in those terms, he says, “We realize that we will need more physician involvement. Dealing with the volume to value change in the practical context of patients coming to our nursing facility to continue treatment for their acute illness, we realized that we needed more physician engagement, presence, and alignment.”
 
“There is an increasing demand for physician presence in the nursing home setting,” says Matthew Wayne, MD, CMD. “We have health care reform sitting in front of us. Regardless of what form it ultimately takes, there are some basic elements that will move forward. One of these is accountable care. Outcomes, patient experiences, and cost-effectiveness all will be looked at, and these data will be used to drive reimbursement,” says Wayne, who is medical director at several Cleveland, Ohio-area nursing facilities. “For me, this is exciting. If we can increase effectiveness, there is a real opportunity to improve care and financial outcomes for the physician, the nursing home, and the health care system as a whole.”
 
Another driver, says Avery, is that long term care centers increasingly are becoming post-acute centers. “Patients once were called residents. They came and stayed for years. But now the average stay is a few weeks or a few months,” he says. “The goal for these patients is to get them home or to an assisted living facility. This has forced us to ask: How do we design a new setting for recovery care? How do we provide the level of care they need? How do we get them back in their community at as high a functional level as possible?”

Physicians In Executive Positions

To help build the infrastructure necessary to meet these changes, Golden Living has a physician chief executive officer, Neil Kurtz, MD. The company also has division medical directors and is developing a plan for regional medical directors. Physician alignment at the corporate level can accomplish much, Avery says.
 
“Having these practitioners internally changes the way we think. In fact, it leads the organization to see physicians as partners and build information systems to communicate and facilitate these partnerships,” he says. “This information exchange is the currency of the partnership.”
 
Avery believes that having physicians in leadership roles sends a positive message to other clinicians. “They see that the organization appreciates and values its physicians. It can improve communication dramatically,” he says. “Physicians have a unique language and are more likely to communicate easily and openly with each other than with others.”
 
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Louisville, Ky.-based Kindred Healthcare currently has four full-time physician leaders at the corporate level to liaise with the medical communities they serve. The company is also beginning to explore and develop a more robust physician services infrastructure, says Keith Krein, MD, CMD, chief medical officer.
 
“Kindred has a physician whose job it is to explore the development of a ‘management services organization’ so that we would be able to offer physicians employment opportunities and back-office functions like billing services, credentialing, and insurance,” Krein says, adding that his company is also considering expanding the number of physicians in leadership and management positions by year’s end. They also plan to hire more physicians in the future for direct patient care. 

Quality Commitment

Kindred’s commitment to an increased physician presence in leadership positions “puts more teeth” into areas like quality improvement, clinical guidelines, pharmacy utilization, and ancillary expense control.
 
“We feel it is imperative to bolster physician services as both the volume and acuity of admissions increase, in order to improve care transitions between hospitals and skilled nursing facilities and move more swiftly at the time of admission in areas like medication management and care planning,” says Krein. “We also are putting more horsepower into medication reconciliation as patients leave the facility.”
 
Additionally, as more physician specialists provide consultation services or supervise specialized clinical programs in the skilled nursing setting, Kindred is committed to having physician leaders oversee the process.
 
Perhaps the most obvious benefit of having physician employees is that they work with the mission of the company in mind. “If a physician has a private practice, those demands will always come first,” says Kevin O’Neil, MD, CMD, chief medical officer for Brookdale Senior Living, Brentwood, Tenn. “Doing what I do now, I actually can change systems of care.”
 
He admits that this can be a bit of shift for physicians who may not be used to thinking about a whole system of care and how they can support the organization and its medical directors in their efforts. However, he stresses that it is well worth the investment. It also can be a very exciting role change for these physician leaders.

The Power Of Physician-To-Physician Encounters

Externally, having physicians talking to physicians in other organizations and agencies can have a powerful impact.
 
“We got involved in a health information exchange in Indiana because we had our physicians talking to physicians at the state level. This enabled an exchange of clinical information between our facilities and acute care settings in the state; when our patients went to the emergency room, their information was readily accessible to the treatment team there. From health care systems to medical centers, this type of communication is fundamental,” says Avery.
 
“I spend a great deal of time talking with managed care medical directors and going to the hospital to talk about physician services and medical oversight. And some state surveyor agencies have physician medical directors,” says  Karyn Leible, MD, CMD, chief clinical officer, Pinon Management, Lakewood, Colo. “Having a clinical knowledge base that other physicians can relate to is very helpful in these interactions.”
 
Avery also offers a personal experience that showed the value of having physicians as part of the facility’s team.
 
He was senior medical director at a hospice in a state that had very low rates of hospice utilization. To bring in more patients, Avery hired full-time physicians and had them dictate notes. These, in turn, were sent to physicians at medical centers to increase communication between settings. “Once our physicians started talking to other physicians, integration started to occur. In five years, our census quadrupled,” he says.
 
When clinical excellence is part of the organization’s mission, “you have to get physicians involved internally,” says Avery. Golden Living has medical director town hall meetings. “These are conference calls where the physicians at our nursing facilities tell physician leaders what is working well and where they need assistance,” he says.
 
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These meetings have led to several innovations. For example, the medical directors expressed a need for more guidance in their roles, so Golden Living developed a Medical Director Handbook. The physicians also indicated that they didn’t know what to do during state surveys, so the company came up with a medical director survey checklist with specific tasks that a medical director should complete before, during, and after a state survey.
 
“One medical director told us that nurses sometimes confuse very early pressure ulcers with rashes, so we were able to identify this as a possible gap in training and address it promptly,” says Avery.
This kind of ongoing communication is essential to establish and maintain medical director communication, competency, and engagement. “We want them to be seen and to see themselves as part of the leadership team,” Avery says.
 
To encourage this, the company pays for American Medical Director Association (AMDA) membership for its physicians, gives a stipend for physicians who attend the AMDA annual symposium, and offers incentives to medical directors who pursue the certified medical director (CMD) certification.

Facility Physicians: An Early Trend

“We’re engaged in discussions about hiring physicians in our homes. It’s not that far off,” says Leible. There are many drivers behind this effort, but it is especially appealing in rural areas where it is difficult to attract physicians for visits.
 
Wayne says, “If we have physicians with reliable hours in the nursing home, we will improve communication, relationships, and outcomes. The better the care, the less likely we will have issues such as inappropriate hospitalizations. Moving in this way, we have a chance to create wins across the board.” He predicts that there will be a move toward fewer but more committed clinicians practicing in facilities.
 
“Our goal is to hire a full-time physician for each of our nursing homes across the country. The reason is simply to provide the best quality of care we can for our residents,” says Kenneth Scott, DO, corporate medical director at Life Care Centers of America. “The employed physician not only attends to the medical needs of the patients, this practitioner also helps educate the staff within the facility and provides meaningful insight into processes within the building to improve care and coordination of care,” he says.
 
The physicians play a direct role in communication with physicians in private offices and hospitals to ensure safer care transitions, as well as being active in improving patient and family satisfaction.
There is a cost associated with hiring physicians at the facility level. “Obviously, physicians don’t come cheap,” says Scott, adding, “It is somewhat less expensive, however, to add them to your employee pool of benefits, compared to covering the cost of an independent practitioner who must go out independently and obtain his or her own benefits—often at a higher cost.”

Gauging The Pluses

At the same time, offsetting the costs are numerous advantages. “We hope to do our part in answering the call for higher quality of care at less cost. We know that great physician involvement will result in better care,” Scott says.
 
There are numerous advantages to having physicians who have regular schedules in the facility; a relationship with staff and patients; and a buy-in regarding policies, procedures, processes, and protocols. “This is an opportunity to hire physicians who share your standards of care,” says Leible. She adds that improving census is another benefit, and while it may be the one that drives some organizations to embrace an increased physician presence, it likely will be only one of many positive outcomes.
“Over time, it will help enable fewer hospital readmissions, increase regulatory compliance, reduce antipsychotic use, and [reduce] medication errors. Ultimately, it will help improve the finances of the facility,” Leible says. But to make this happen, she notes, the organization has to be forward thinking and realize the value of investing in physicians.

Benefits For Doctors

There also are benefits for the physician. As Scott says, “There is a sense of belonging. Being part of a larger group or company provides security. Many doctors are seeking to be employed in the face of an ever-changing health care landscape that provides no security for an independent practitioner.” He adds, “The SGR [sustainable growth rate] formula threatens to bankrupt many practices overnight if [further] cuts are implemented. There is some relief for physicians to know that their salaries are guaranteed and that they can truly focus on good patient care.”
 
Physicians also like the idea that the cost of health information technology—such as electronic medical records (EMRs)—will come out of the company’s pockets and not theirs.
“The requirement to have meaningful use of EMRs is daunting for many solo practitioners and threatens to lower their income through penalties for not conforming. A uniform system provided by the company, such as hospitals are incorporating, relieves the individual practitioner of the burden,” says Scott.
 
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Does Physician Involvement Make A Difference?

Clearly, there is much anecdotal information to suggest that a commitment to physicians at the corporate and facility levels has a positive impact on care, outcomes, and costs. But organizations are starting to measure the results. For example, Golden Living uses a medical director assessment tool that enables nurses and others in the facility to evaluate the medical director.
 
“We want to reward those who are doing well and assist those who need help,” says Avery. The tool has made a difference. The results from its second year of use showed a dramatic increase in physician participation and engagement over the first year.
 
One study found that nursing facilities that had a CMD serving as a physician leader provided higher-quality care. Analysis of nationwide data showed that quality scores represented a 15 percent improvement for facilities that had CMDs at the helm.
 
As more organizations bring physicians into leadership roles, there likely will be formal studies relating their involvement to outcomes and costs.
 
In the meantime, some groups are focusing on defining the skill set needed to practice in this setting. These don’t apply just to physician employees but also to those physicians who specialize to some degree in long term care.
 
Wayne is working with AMDA to develop such competencies. “Some people think of long term care as geriatrics. But while there is an overlap, it is different,” Wayne says. “My sense is that the overlap is in medical management.”
 
However, he notes that while most physicians with an internal or family medicine background have some exposure to the evaluation and management of dementia, delirium, and other diseases common in the elderly, there is more to long term care patients. “These aren’t just older adults. They are mostly medically complex and frail elders—a distinct subset of geriatrics,” says Wayne. “In this setting, you also need to skill set to manage a higher level of acuity in transition, including medically complex patients with profound functional impairment, and address goals of care for these individuals.”
 
These physicians also need an understanding of the unique long term care regulatory environment. “There is a real need to define what a successful physician in long term care looks like and what skill sets they should have,” Wayne says. He emphasizes that an overriding theme of the approach to this is inclusiveness. “We have psychiatrists, surgeons, hospitalists, and others working as long term care physicians. Our intent is to welcome any and all of these people with open arms—with the caveat that they must have a passion to care for this population and a willingness to ensure they have the necessary skill sets.”
 
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Using Their Skills

Wayne gives an example of  when having the right skill sets for long term care made a positive difference. One of his facilities admitted a man for rehab. He had advanced cardiac and renal disease, and once in the facility, he experienced exacerbations of heart failure and developed Clostridium difficile diarrhea.
 
“There were times that I needed the skill sets to manage higher acuity. The patient required two to three visits per week to maintain medical stability,” he says. “It became apparent that his disease states were end stage, so we moved into palliative care mode and had discussions with him and his family about what he wanted and how to keep him comfortable.”
 
The patient and his family ultimately embraced hospice, and the result was a winning situation for all involved, according to Wayne.
 
“It was a win for the patient because his needs were met without unnecessary testing and hospitalization, and for the family because they felt involved and informed. It was a win for the facility because he wasn’t transferred to the hospital and for me because I was able to be efficient and effective. The hospital won because he wasn’t readmitted, and Medicare won because we avoided the expense of an additional hospitalization. If we raise the bar and do this consistently, everyone walks away with a win,” he says.
 
The skill sets are only the first part of the conversation, Wayne stresses. The second piece is the model of how these practitioners will work, he says.
 
With regular times and days in the facility and consistent processes and protocols to follow, the practitioner is “more effective the minute he or she walks into the building.” Physicians also need to understand the importance of establishing other logistics such as how they will communicate with patients and families and how to make the facility an alternate office setting.

Physicians And Care Transitions

Some organizations are involving physician employees in overseeing and improving care transitions. Brookdale has made this a priority through a care transitions improvement project in Cleveland with Wayne. He is working on developing protocols and checklists for physicians and staff. The goal is to have a system in place that prevents issues and information from falling through the cracks.
Wayne also is working with nurse practitioners in skilled and assisted living environments to promptly address changes of condition.
 
Elsewhere, Brookdale is working with Joseph Ouslander, MD, professor and senior associate dean for Geriatric Programs at the Charles E. Schmidt College of Medicine and executive editor of the Journal of the American Geriatrics Society, to develop a curriculum around the use of INTERACT (Interventions to Reduce Acute Care Transfers) tools. “This is an important area to focus on. I’ve always felt that mass collaboration is the key to the future of effective care transitions,” says O’Neil.
 
With accountable care organizations coming fast and furious and care transitions continuing to attract national attention, the growing role for physicians is more than a trend. According to industry leaders such as Leible, “It’s the way of the future. As we have more medically complex residents and there is more emphasis on outcomes and quality improvement, physicians can help achieve desired results.”
 
Joanne Kaldy is a feelance writer and communications consultant based in Harrisburg, Pa.
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