As resident acuities rise and reimbursements more closely link up with resident results, boosting physician services in skilled nursing facilities has emerged as a potential strategy to improve both outcomes and income — whether it’s through in-person visits or telehealth.
In the northwest corner of Washington state, Swenson Healthcare has been taking something of a hybrid approach, launching an in-person model in January 2018 with plans to soon bring psychiatric telehealth services to rural SNFs.
The Tacoma, Wash.-based physician group currently serves more than 30 facilities in the region, with a team of 30 physicians, nurse practitioners (NPs), and physician assistants (PAs) performing rounds at facilities five days per week. So far, according to CEO Darren Swenson, certain buildings in the network have achieved hospital readmission reductions of 20% to 30% after using the company’s services, though he also noted that the returns are early and not necessarily consistent across all of their clients.
Swenson says he based his strategy on the care models he observed during his time as a hospitalist, including a stint as the chief medical officer of MountainView Hospital in Las Vegas — as well as a general dearth of physician options for skilled nursing providers in the Tacoma region.
“They had not really had many physicians who were interested in taking care of the post-acute patients,” he said.
SNN spoke with Swenson to learn more about how a company builds out a network of SNF-focused physicians, as well as why the model might seem attractive to Medicare Advantage payers.
What kind of reception are you getting from operators? Are they worried about costs, or the office politics of integrating third-party physicians?
A very positive reception. We’re actually trying to manage the amount of requests we’re getting. Our business model is structured where we don’t charge the facility any fees to staff the building. We take full responsibility and full risk on Part B billings, when appropriate.
If a facility has a desire or a need for our leadership, our medical leadership of our physicians to provide administrative support as medical directors, then we set up a contract for that based on the facility’s identified need. But we don’t charge a fee to staff the building. We’re there to take care of the community.
Do you have any evidence on outcomes so far?
We’re starting to develop those dashboards now, this year. We hired a chief nursing officer, Sarah Walden. She’s a former director of nursing for post-acute buildings for many years, and we actually created that position in the post-acute space for two purposes: Number one is to build the dashboards and track the metrics on clinical outcomes.
And we’re starting to get some early data where we’re seeing about a 20% to 30% reduction in readmissions, but it’s not consistent. We see it in some buildings; other buildings, we’re seeing less. It’s really building-dependent, because you’re dealing with different staff in each building and different resources in each building. We’re the consistent thread with our model, and our model’s pretty much regimented for our providers, but the variable is the nurses, the staffing levels, et cetera.
We’re seeing some reductions in the cost of medications, because we work with some of the big pharmacies like OmniCare. We work closely with them right now, where we’re sharing data to identify high-cost meds. We’re identifying which facilities and patients that have polypharmacy — the number of patients with greater than 18 meds. We’re also looking at patients who are on a lot of anti-psychotics. And we’re targeting those patients, because of our assistance and partner with OmniCare, to really reduce the number of anti-psychotics in those patients. The data’s being built. We don’t have enough data yet to say we have truly consistent trends.
What’s your pitch when you go to providers?
Can we fill a need that you have? I really try to stay away from the marketing, the sales pitch per se, but it’s more of: We provide a service. Our service is 100% focused on post-acute. I don’t do hospital medicine. We don’t do assisted living. We don’t do acute inpatient rehab. We are 100% post-acute, long-term care. We’re becoming experts in that area.
Number two, we provide a service in the community where we want to improve care by being more visible, more present in the buildings. It just stands to reason that if you have a doctor visiting once a week, or a provider in the community visiting once a week, but they’re running a full-time practice, or they’re distracted by another part of medicine, they’re not going to be readily available and provide the best outcomes.
IF we’re in the building five days a week, and this is all we do, it’s highly probable we’re going to improve outcomes, improve patient experience — which is going to give you an edge in terms of attracting patients, and showing your hospital partners that you can provide better outcomes. That’s really the approach that we take with our facilities.
Number [three] is we built a post-acute-focused leadership team. Ray Thompson, who’s our president, has been involved in post-acute for 20 years. He was a division vice president for Life Care. He understands post-acute and their needs. Sarah Walden’s our chief nurse, former director of nursing for five years. She had two years of citation-free surveys. In Washington, it’s really tough to do that.
So she understands the regulatory component. She brings that knowledge and experience to the table with our providers, many of whom are not from the post-acute world — makes sense, it’s relatively new space of health care — and she’s teaching them about the regulatory component. How to avoid F-tags for the buildings. How to partner with proper documentation so that the facility does better in their surveys. Everything is about the five-star rating. If we can be the better partner to improve quality measures and to support and teach nurses and be readily available, it stands to reason that the facilities are going to do better on their ratings over time.
We have a dedicated chief medical officer who’s been in post-acute for years, and he’s there to train the physicians and the nurse practitioners and PAs about how to be better clinicians in post-acute medicine.
When you build a physician network, it’s not always the operators you want to partner with — have you heard interest from payers in the space?
Optum is the large provider here in the long-term space, and so when we came into town, they had a very similar model. They provide nurse practitioners to take care of those risk patients in the long-term care setting. They provide a great resource to the community: the primary care doctor, or a doctor whose full-time job is other than post-acute, so Optum provided that value. Now with our model, we’ve had a little bit of overlap. Our nurse practitioner’s in the building five days a week; Optum’s there as well, taking care of those patients.
We’ve worked with Optum on how to partner and collaborate and support each other, and to support the common patient — but without duplicating efforts, duplicating cost. We just got data back from Optum … the admissions per thousand has improved down to just a little over 200, which is a remarkable number in the managed-care space. Our number of lives continues to increase rather significantly. We’re taking care of more lives in common with Optum, and yet our performance is improving exponentially. It just goes to reason because we’re in the building.
What’s your plan for behavioral health?
This has been a common theme from almost every building partner we’ve talked to, or buildings who invited us to come chat about our program. It’s usually in the first few minutes, a question comes up from the building operator: “Do you provide mental health, psychiatry services? Do you have a connection? Do you have someone you work with? We are struggling to find that resource for these patients.”
Over the last year and a half, here in Washington, that theme has been common — especially more in our rural communities. When you get outside of King and Pierce County, it’s a lot of rural communities here in western Washington. As we look at working with our partners on PDPM and on proving outcomes with anti-psychotics, we just felt it was really important to get the expertise on our team — not only to care for the patients in the building, not only be a resource for the buildings and their patients, but also to be a partner for our clinicians, to help teach them and guide them on how to care for these patients.
We have an opportunity now as we launch a new service line called Swenson Psychiatry, where we’re going to be able to not only have a board-certified psychiatrist — who understands gero psych and long-term care patients — care for these patients on site, we’ll also be able to do it through tele-psychiatry into more of the rural communities. But we’ll have a psychiatrist and mental health nurse practitioners who’ll be able to collaborate with our medical providers to give the best outcomes to these patients. We’re really excited about this.
What’s the timeline?
The psychiatrist will start services in August of this year, and we anticipate starting tele-psychiatry for the rural communities in the fourth quarter of this year, and we anticipate having our mental health nurse practitioner on board in the fourth quarter. Between the mental health nurse practitioner and the psychiatrist, they’ll be able to provide those services based on need and requests from our facilities, across western Washington.
What does that look like from the patient and operator perspective?
It’s really based on need. You have to have medical necessity to care for these patients. Sometimes we get patients who are on psychotropic medications from the hospital, but there’s not clear documentation why they’re on the medicine. Sometimes the patient or family can tell us, or they can’t. And that’s where we need the expertise of the psychiatrist or the mental health nurse practitioner to really dig in and evaluate: What is the indication, what’s the purpose, and is there an opportunity to do a dose reduction or even transition the patient off this medicine? We don’t know why they were started on it in the first place.
More importantly, we’re hoping, in the future, to be able to better understand mental health in post-acute, and then to connect that back with the hospitals and the hospitalists, and try to educate them about the post-acute space and some of our challenges with psychotropic medicines, and why we’re really focused on avoiding them whenever possible. But that has to start with understanding our patient population here in western Washington.