This article is sponsored by Sound Physicians. In this Voices interview, Skilled Nursing News sits down with Sound Physicians National Medical Director Dr. Brian Carpenter to learn how Sound became a leader in the post-acute space, what COVID-19 might mean for telemedicine, how Sound Telemedicine (a division of Sound Physicians) has managed to treat 93% of residents in place — and how they manage hospital transfers for the other seven percent.
Skilled Nursing News: Brian, you’ve been with Sound Physicians for coming up on seven years with several titles, along with, of course, a long career prior to coming here. What stops along the way are the ones that you draw from in your current position?
Dr. Brian Carpenter: I started my career in hospital medicine back in 2006 in the suburbs of D.C. and Maryland, and was employed by a regional hospital medicine group with a small core group of doctors. We were all young and eager to take on the world. A few years after I started working there, I was asked to take on the role of the chief hospitalist, and in 2009 is really when I stepped into my first hospital medicine leadership role. I dove right in. What really excited me about being a leader in hospital medicine were the endless possibilities of how what I was doing in hospital medicine could impact patient outcomes — not just within the hospital, but out into the community.
I joined Sound in 2014, when they acquired our group. What I clung to was Sound’s commitment to one of their core values: innovation. Sound really supported their local hospitalists across the country to improve patient outcomes, and they had strong, robust platforms to support our efforts in driving quality improvement.
You talk about Sound’s innovation — how did the company enter the post-acute space?
Carpenter: Our initial service line, hospital medicine, started in one hospital in the Pacific Northwest in 2001. We’re now in 41 states with over 1.5 million annual hospital admissions per year, and we’re the largest physician group enrolled in BPCI-A (Medicare Bundled Payment for Improvement – Advanced) with $2.5 billion at risk annually.
In 2014, we started taking risks on the total cost of care for anyone who was hospitalized. That meant we had to think about the cost-benefit for delivering inpatient care, but also how we were managing patients in the post-acute space.
Sound invested heavily in developing and educating our doctors and advanced practitioners around the main goal of value-based care, which was to improve clinical outcomes while decreasing costs. They also invested in developing levers that we could pull to achieve those goals. The focus is discharging patients to the least restrictive, most appropriate next site of care that is aligned with the patient’s advanced care planning and goals of care. We don’t want to send patients to an inpatient rehab when they need a SNF, or to a SNF when they really should go home.
From the beginning, we saw great outcomes from our initial endeavors in bundled payment and value-based care, and we saw decreased hospital readmissions and decreased total cost of care for our entire population. But there was still inconsistent improvement in patients who went to nursing homes, especially around hospital readmissions.
Our Tele-SNF service line was really born to help increase SNF access to physicians who are trained in treating acutely ill and higher acuity patients, no matter where they’re located. Specifically, we want to help skilled nursing facilities address readmission opportunities and treat their residents in place. We’ve taken our early education in value-based care and used it as the backbone of developing our Tele-SNF program.
Obviously telemedicine exploded during COVID-19, and there are a lot of solutions. How do you describe what you do?
Carpenter: Sound Telemedicine provides access to high-quality, board-certified physicians to support care for patients on nights and weekends in skilled nursing facilities through the use of technology. We are not a technology group, we’re a provider group, first and foremost. What we bring to the table is Sound’s knowledge around building exceptional clinical protocols, robust provider management, and client nursing and resident engagement.
SNFs were battered in 2020 like never before. What was it like for you to see them persevere?
Carpenter: The first outbreak really affected skilled nursing facilities, and we saw the devastating toll it had across the country. It wasn’t just the residents and the staff who were infected or affected by the virus, but also the loved ones of the residents in the nursing homes.
The key here is isolation. It wasn’t just personal isolation, which certainly happened in this pandemic. The SNFs were also isolated in many ways from the rest of our society as a whole. In particular, they were isolated from their number one referral source.
Hospital medicine saw a big drop in volumes across the country. The downstream effect was that SNFs also had lower volumes, but they had much sicker patients. Yet they were working hard as this pandemic raged across the country to do positive things for their residents. They created COVID wards, they implemented testing and isolation protocols and they worked with local and national groups like Sound to implement telemedicine so that their residents still had access to high-quality physicians to care for residents and support the staff.
Over time, we saw the emergence from this isolation, and the resilience of our SNF partners. They always kept the focus on the residents to do the best that they could. This was an opportunity for us to fill in what was already a widening gap of physician coverage. You have physicians who can’t get to buildings and you have physician shortages in nursing homes, particularly on nights and weekends. The pandemic just exponentially exploded the staffing problem.
Sound Telemedicine and SNFs were looking for innovative ways to provide access to high-quality physicians. In some ways, the positive outcome of the pandemic was higher acceptance of telemedicine and a faster adoption of telemedicine across nursing homes.
Definitely. In your view, what is a key area of support that is missing from other telemedicine systems, if you had to pick one?
Carpenter: The one I would say is clinical protocols to treat residents in place. During our go-live and discovery process, we’ll work with SNFs to understand the unique capabilities in each building because not every building is the same. Some can take care of higher acuity respiratory patients, others have onsite labs, others have radiology that has to be brought into the building, so with our understanding of the resources in that building, we can build what we call an operational guideline.
Those operational guidelines are critically important for our providers to know how they can develop clinical care plans for the residents in a specific nursing facility to treat more residents in place. They can also be used, and should also be used, by the nursing homes to onboard new staff, and help ensure our telephysicians are completely aligned with the nursing staff on the capabilities in the building to care for that resident population. Because of this, we’ve been able to drive a robust treat-in-place rate, where 93% of our encounters result in treating the residents in place.
What happens in the case of the other 7%? How do you handle hospital transfers?
Carpenter: When we have to send a patient to an emergency room, we initiate what we call our ED management protocol. This is really a white-glove service for managing transfers. Any transition of care will put a patient at risk for negative outcomes and we want to assure that we go above and beyond to mitigate those risks. Our provider will have a peer-to-peer conversation with the ED provider where the patient is going to be sent to.
There are two purposes to this call. The first is to provide directed guidance on what we expect out of the visit, because these are medically complex patients and it’s easy for the ER providers to get sidelined by chronic stable medical conditions and lose focus of really why the patient is coming to the emergency room in the first place. So that conversation is driven to direct that care while they’re in the emergency room, and also the workup.
The second purpose of that peer-to-peer is to reassure the ED staff that we are available to provide hospitalist-level care when the patient is ready to return to the nursing facility, so that the ER doesn’t think that they’re just discharging the patient back into some unknown situation in the nursing home.
We’ve seen great results with this: 25% or more of the patients who we initiate in this ED management protocol return to the nursing facility without getting readmitted. For residents who need to go to the emergency room, it’s one more chance to reduce that readmission.
What is your favorite Sound Telemedicine resident success story?
Carpenter: I have a great one. We had a resident who a nurse was calling us for. They were concerned that the resident was choking, and our physician saw the resident on video with the nurse, realized that the resident probably had a food bolus and initiated the ED management protocol. We called the ED and gave them a heads up on what we were worried about. The ER had a trusting relationship with our Tele-SNF provider and they went ahead and activated their on-call GI specialist who was waiting for the resident when they got to the emergency room. The resident was able to be taken immediately to the endoscopy suite and the GI doctor was able to remove the food bolus, recover them in the PACU and send them back to the SNF.
Lastly, what is most exciting to you about Sound’s position in 2021?
Carpenter: I think there are a couple of things that I’m really excited about. One is that the pandemic has unleashed Pandora’s box of telemedicine. There’s this higher level of acceptance which I think will accelerate adoption of telemedicine. There are exciting new regulatory changes coming that are going to help even further drive adoption by making a lot of telemedicine services reimbursable. We’re already developing clinical documentation protocols for Sound Telemedicine that are designed to drive improvement in nursing home PDPM and their ultimate reimbursement.
Through this experience of the pandemic, we know that nursing homes are going to continue to get higher acuity patients. Telemedicine is really an acceptable way to facilitate nursing homes taking these resident and providing a higher level of support for the nurses in this post-pandemic world that we’ll be living in.
Editor’s note: This interview has been edited for length and clarity.
Sound Physicians is a telemedicine leader connecting hospitalists and SNFs. To learn how they can bring better care to your residents, visit soundtelemedicine.com.
The Voices Series is a sponsored content program featuring leading executives discussing trends, topics and more shaping their industry in a question-and-answer format. For more information on Voices, please contact firstname.lastname@example.org.