This article is sponsored by Sound Physicians. In this Voices interview, Skilled Nursing News sits down with Dr. Adnan Lakhani, Medical Director, Post-Acute Telemedicine, at Sound Physicians, to learn about the key gaps between hospitals and SNFs, and how telemedicine is bridging those gaps to deliver better clinical outcomes. He also explains why there has been resistance to changing the clinical model in SNFs, and what skilled nursing leaders are doing to break through it.
Skilled Nursing News: What led you to join Sound Physicians?
Dr. Adnan Lakhani: That’s a big question. I trained in internal medicine and have a background as a hospitalist and SNFist. I was a physician taking care of patients when they were admitted to the hospital, and also when they progressed their care through a SNF setting. I have an intimate understanding of this frail population, with tons of comorbidities that get discharged from the hospital and go to the post-acute care setting, hoping to eventually go home.
As a result, I saw the realities, the difficulties and the challenges faced by post-acute care facilities, patients, health systems and payers. I was looking for a way to innovate and provide health care that addressed those challenges from a systems approach.
An opportunity came about with Sound Physicians, and I got started in their post-acute care telemedicine program. When I spoke to Sound’s national medical director for telemedicine, Dr. Brian Carpenter, I was wowed. Sound was doing something that not many organizations had thought about. It’s a simple idea: When patients go to a nursing home, give them more physician engagement – like what they would get in the hospital setting.
When Dr. Carpenter told me about this endeavor, I was super excited. This was an opportunity for me to change things at the system level, innovate and change the way we practice medicine by providing nursing home patients with increased physician engagement on nights and weekends.
What career experiences do you most draw from in your role today?
Dr. Lakhani: I frequently look to my experience as a SNF physician and hospitalist. Having that acute care and post-acute care clinical experience helps me better understand the pain points of a patient as they travel through this continuum of care.
That experience enabled me to be innovative with Sound Physicians when I came on as their medical director, and that’s one of the main reasons I joined their team. We meet every month and talk about reducing readmissions and increasing quality of care. The goal of Sound is to think out of the box, and their telemedicine approach embodies that idea.
What are the key gaps you see between hospitals and SNFs, and how do they negatively impact patients?
Dr. Lakhani: One of the key gaps is communication. For instance, when a patient is discharged from a hospital to a SNF, most get the discharge med list but not the physician discharge summary. From a hospital’s perspective, that discharge summary is done either before discharge or within 24 hours of the discharge. That’s because the hospital is sitting in a different EMR and that crosstalk isn’t very smooth.
When the patient leaves with those printed papers, sometimes that physician discharge summary doesn’t get printed. This is the fine point. The physician discharge summary is a review of the course of events, and even when they get printed properly, the physician notes are often left out.
A lot of other stuff is transmitted, but sometimes it doesn’t provide the meat and bones the SNF needs to see. Helping our SNFs get better access to the hospital’s EMR and the physician discharge summary is a key area for improvement.
On the flip side, when a SNF patient has an acute need that requires a transfer to the hospital, we can improve that communication as well. That detailed, active physician-to-physician communication from the SNF to the ER prevents redundant work and unnecessary care.
What kinds of conditions can be managed successfully onsite at the SNF using telemedicine?
Dr. Lakhani: One of the biggest things we manage is tucking in new admissions. Often SNFs get delayed admissions or late admissions, and we can address them very effectively via telemedicine. With a virtual visit in the evening or on the weekend, we can ”tuck that patient in” and make sure their medicines are appropriately resumed or ordered.
The second thing we manage is any acute decompensation, heart failure exacerbation, COPD exacerbation or UTIs. With those, we can see and assess the patient virtually and order labs, IV, antibiotics, nebulizer treatments or Lasix and diuretics.
Our third most common area of management is pain control or patient preference. These patients are human beings with needs. They’re frail patients. Sometimes they’re upset, sometimes they have pain needs, and a physician’s presence through telemedicine can really make a patient feel that we care and that we value their feedback, concerns and questions.
When patients need to go back to the hospital, what role does the tele-hospitalist play, and what are the major benefits that role provides when those readmissions do occur?
Dr. Lakhani: I would say it’s a three-step process. The first step is to see the patient and determine if we can intervene within the SNF building to prevent an ER visit.
Once the decision has been made to send the patient to the ER, the second step is a conversation with the ER physician. Our doctors call the ER physicians once when the patient is en route to the hospital to provide a handoff, and they call again in a couple of hours to follow up.
The thesis is that just because a patient goes to the ER, does not mean they need to be admitted to the hospital. Often, this second step leads to opportunities where a patient, after an ER workup, can go back to the SNF with a plan to take care of them.
The third step is communicating that finding with the primary SNF team. After our physician does all of this, we write a detailed progress note that is transmitted to the primary SNF physician or team that follows up the next day. When this patient comes back, they can get appropriately followed up with for the next couple of days.
How does an on-shift tele-hospitalist address staffing challenges?
Dr. Lakhani: That’s a huge issue for everybody around the country. I saw firsthand how incredible our frontline SNF nurses, LVNs (licensed vocational nurse) and SNF leadership are. They really do a lot with a little for some of the most complicated, frail patients. As a result, our service handles physician engagement at night and on weekends to absorb the high patient burden. The night shift staff knows, “I don’t have to worry about bothering a physician because this physician is not sleeping. When I need something this physician is awake, on shift, just like me, in the middle of the night, whether it’s 9:00 PM or 3:00 AM.”
I think that level of physician support gives confidence to a facility because they know support is available during their shift. Our SNF nurses and LVNs feel refreshed, even when these SNFs are basically acting like mini-hospitals with very complex patients. We want to provide that hospital-level physician presence in off-hours to empower SNF nursing staff.
Why do you think there has been resistance to changing the clinical model in SNFs, and how are leaders breaking through it?
Dr. Lakhani: I think the resistance stems from three big buckets. The first bucket is from the provider perspective. You have SNF physicians, medical directors and providers doing their best to provide great care in limited settings. Their call burden on nights and weekends is tremendous, but they still feel concerned that on-shift telemedicine services like Sound could diminish the patient experience.
We know that’s not the case at all because we’re there to serve as an extension of the physician. But there is still a trust issue we have to overcome as another group of doctors is involved in the patient journey
The second bucket is poor communication. SNF physicians need to be informed properly so that when we see a patient, they receive a detailed note of the visit. We believe communication is very important, and it’s our job to make sure the SNF physician gets everything they need from us.
The third bucket of resistance is change management. It takes time for physicians, providers, nurses, DONs and administrators to adjust to something new, even when we make the process easy.
Coming into this year, no one knew fully what to expect in the skilled nursing industry. What has been the biggest surprise this year, and what impact do you think that surprise will have on the industry in 2022?
Dr. Lakhani: One of the biggest surprises is the pandemic’s impact on census: how it’s fluctuated, how it’s negatively impacted some facilities and how we’re trying to find more effective ways to avoid unnecessary hospitalizations. There is a new dialogue because hospitals, SNFs and the post-acute care space in general are trying to keep more complex patients from returning to the hospital
That’s where we come in. Our service at Sound is another tool in the toolkit. It’s not the final solution to all the problems, but it addresses the physician engagement component. It provides support so SNF facilities can maintain their census and keep more complex patients within their walls. That’s been an eye-opener for me.
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 [email protected].