New Physician Group Targets ‘Tremendous Challenge’ of Readmissions, Clinician Turnover in Skilled Nursing

As hospitals have increased pressure to reduce post-acute lengths of stay, and nursing homes take on higher-acuity patients, the skilled nursing space has grappled with the dueling potential for great financial gains — along with heightened risks in appropriately managing this population.

One emerging strategy focuses on embedding higher-level clinicians, including physicians and advanced-practice nurses, in skilled nursing facilities, either in person or through telehealth solutions. And while the prospect can be expensive, treating residents in place has demonstrable benefits for spending reductions and improved resident outcomes.

A new medical practice group sees opportunity in providing multi-resource support — through back office and clinical expertise — to help post-acute facilities navigate the new payment world, and potentially improve health outcomes and data analytics. 

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Darren Swenson, CEO of the Washington state-based Swenson Healthcare, spoke to SNN in July about his company’s plans to build out a network of SNF-based physicians for psychiatric health in the post-acute space. Swenson reported that a number of nursing home buildings received a 20% to 30% reduction in hospital readmissions after using the company’s services.

Swenson recently expanded his post-acute footprint with the launch of US Post Acute Care (USPAC) — which provides management support for other SNF-focused physician companies. He believes the model can help post-acute providers reduce hospitalization readmissions, the use of antipsychotic medications and opioids, and falls.

Swenson — who’s in the process of bringing USPAC’s services to providers in the Northeast, Southeast, and Texas — recently spoke with SNN about his ventures, and how operators can thrive with higher-acuity residents.

I’m curious how you’re transitioning from Swenson Healthcare to this new venture, and what prompted you to launch USPAC.

I’ll start with why we launched US Post Acute Care. I see a real opportunity for a clinically-focused organization to provide business management and administrative leadership in the post-acute space on a multi-state level. If you think about it, traditionally, post-acute clinicians have had very little choice to rely upon wherever support was made available from the facilities or their employers — whether it be a multi-specialty group or even a health system. And that’s just not really good enough for the clinicians for several reasons.

What inevitably follows, I think, is the frustration on the part of post-acute facilities with turnover of the clinicians and sub-optimal care for patient — and we think as USPAC that we’ve got a better way of doing this.

Historically, none of the employment models are designed from the ground up to meet the specific needs for post-acute medicine. That’s exactly who we are. We’re a management services organization that’s built from the ground up. We serve the patients with specific needs with clinicians in the post-acute space. And the tie-in is Swenson Healthcare — that was an example of a clinically built, ground-up practice focusing only on post acute medicine, and then now we’ve launched the USPAC to provide that management services support for a group like Swenson Healthcare.

What are some of the ways you are honing in on some of these problem areas, such as employee turnover, for example?

It’s a tremendous challenge out there for facilities, for providers — and ultimately the patient. That’s what we’re all here for, the patient. If you think about post-acute medical practitioners and providers, we derive great benefit from clinical administrative support when it’s specific to our specialty. And post-acute is a very unique specialty.

Here’s a good example. So USPAC has our own dedicated compliance officer who’s trained as a lawyer and also as a nurse, so [this employee] understands the compliance as well as a clinical side. And our clinicians find tremendous value from that, because she brings a different perspective on the healthcare delivery model.

The clinicians have become a lot more comfortable and confident in their practice under her guidance. And really, where else are you going to find that focus and commitment in the post-acute space?

How does someone like a compliance officer fit into a skilled nursing-focused physician’s role?

So she’s a vice president and a full-time leader with our organization. And for example, here out of Swenson Healthcare, she’s actually gone out and around to the providers — one, just to understand their workflow, understand the challenges in front of them today in 2020 post-acute medicine, post-PDPM initiation. And then understanding and hearing from their challenges and where the gaps are, she creates that education.

For example, we held a system-wide educational conference call, and [the focus was] just talking about appropriate documentation and medical records, how to collaborate and [how to] respond to a state surveyor in a building, and when to reach out for help. What are the rights you have as a clinician when a state surveyor wants to meet with you about a clinical issue in the building?

And with coding and reimbursement changes, how do you handle coding confusion and complexities?

We actually have a dedicated coding expert focused only on post-acute medicine who looks at the providers, coding patterns, and then does audits for them to share with them how their documentation is lining up with the coding. And then [the coding expert], she provides one-on-one training and reports with providers on the audits that were successful, as well as the audits that need further work and opportunity.

We always want to work with clinicians to remind them of the things that they’re doing really well. Not too often someone tells us as clinicians what we’re doing really well. By the same token [we assist] where there’s opportunity [and ask]: How do we help them to avoid any red flags with CMS and other insurance companies?

Is there anything in the post-acute space that you feel is particularly challenging at this moment?

There is so much challenge every day. Gosh, we’d be on the phone for a couple of hours.

What we see is really the opportunity to provide a consistent and sustainable way to deliver care and to support the clinicians. If we can help take care of and train and support the clinicians in the field with regulatory compliance, administrative support for billing, leadership, clinical excellence programs — all those fundamental values that a clinician needs — then a clinician can spend more of their time caring for the patient in the post-acute space.

A patient in a post-acute environment needs to be treated as a unique patient. They’ve transitioned, typically, out of a dynamic acute-care hospital, and they’ve moved to another location with a different set of providers. Here we have the idea of: Now that CMS is looking to decrease length of stay in the post-acute space, patients are coming with greater severity of illness because the length of stay in the hospital is shorter [in order to] manage the cost of delivery in the health care system.

And, quite honestly, we’re out there trying to create a model that ensures that these patients do as well to reduce their readmissions and help them get home or to the next level of care safely.

Is there more of a concern about overuse of antibiotics right now?

There is, and there’s actually a law passed several years ago, I think, by former President Obama, about antimicrobial stewardship. And then what we see is the requirement to have a standard approach to antibiotics — and now part of the state surveys about your antimicrobial stewardship program. We stayed ahead of the curve by formalizing this and actively helping our facility buildings and the clinicians to understand what a robust antimicrobial stewardship program looks like.

What does your program regulating antibiotics look like? Would it also ensure the right antibiotics are being used for the correct diagnosis?

It’s really about just making the fact that we’re utilizing antibiotics for patients in the building top of mind. Okay, one, who’s on antibiotics? Why are they on antibiotics? What is the evidence-based medicine about the appropriate use of antibiotics in a post acute environment?

Would you say your regulation of antibiotics is a similar response to the opioid crisis and reduction of antipsychotics, or is it a bit different?

That’s exactly right. It is, once again, to use appropriate indication — and equally important is appropriate documentation in the chart. It’s helping these providers to remind them of the many things they have to do every day for each patient. Are we documenting to support our clinical decision making?

Is there something that you’re working on getting the kinks out of — perhaps something you’ve learned from your other business with the telehealth psychiatry?

So mental health is a great example. As we went out in 2019 to launch mental health for the community here in the Pacific Northwest, we thought we understood the gravity of the need for mental health for the post acute patient and families. And as we began to staff that and work with mental health clinicians, the paucity, the lack of the number of clinicians who specialized and understand this field was much greater than we anticipated.

So we have now recalibrated to look at a different approach to service the needs of those patients. And what we’re looking at is telepsychiatry, and telemental health as being the right scalable and sustainable solution to this.

I‘m trying to picture how that would work because I know there’s all these HIPAA laws with psychiatry and telehealth. What are the challenges with telehealth psychiatry?

If you think about the patients who are in the post-acute space — and we’ll focus on long-term care, those patients are more senior in age and disease pattern. The idea of using technology is very different for them. They didn’t grow up with the iPad; they didn’t grow up with FaceTime. And they grew up sitting down with a clinician at the bedside with them.

The health care system in America is introducing telemedicine because there just aren’t enough [options] to adequately treat enough patients in the mental health space.

And so how do we use technology to reach more patients, especially in the rural communities? We use technology because we can reach several patients in a facility in a remote rural area, and then be able to go on to the next building; that clinician is sitting behind a computerized system with FaceTime or telecom telehealth to communicate with different patients in different locations without having to drive building to building. And this is a great example of how we use technology to meet or exceed our patient’s needs.

How many nursing homes are you working with, or how many you plan to assist?

It’s not more of a metric about how many homes or facilities we plan to care for. The way we look at it is: How many clinicians out there could benefit from our services? How do we help them to be more efficient, to have more time to focus on patient care at their facility, and then allow our organization to be not only their support, but also continue to make them competitive in their market by providing better services?

I’m curious if telehealth incorporates intake from beginning to end — and what are the regulations with the opioid crisis? Psychiatry can be complicated with this population; they may have comorbidities, and if a patient is on several medicines, what is the right approach?

These patients have a significant number of medications [and] chronic medical conditions right now. Your point is well taken; it is the drug interactions we always worry about. With chronic problems, medicines get added because we’re trying to sometimes treat a change in clinical condition.

But we could do a better job, as clinicians, going back and saying: Is that medication still indicated? Has a problem been resolved? Many times we get distracted and we’re not going back to challenge ourselves to de-escalate — to reduce the opioid, to reduce the antipsychotic, to reduce the anti-anxiety medicine because the patient has resolved their change in condition.

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