Physicians are needed more than ever in a nursing home, industry leaders and researchers say, as the sector continues to move toward a setting with higher acuity patients.
And the role may become more attractive to prospective clinicians as the post-acute care setting isn’t “tainted by bureaucracy in medicine,” according to Dr. Justin DiRezze, CEO of comprehensive medical group Theoria Medical.
Physicians dedicated to the nursing home space, sometimes called SNFists, don’t have to deal with the red tape of medical committees and decision trees involved compared to other types of corporate medicine, added DiRezze.
Instead, the SNFist is able to affect a patient’s life directly, along with the protocols and processes within a particular facility, he said.
“Nowhere else in medicine is that available,” DiRezze said, who is also a practicing doctor.
The term SNFist, much like a hospitalist in acute care settings, is used to describe the nursing home physician that has more than 90% of their billing claims based on nursing home care.
The term is only about five or six years old, according to a deep dive into the role published in the Journal of the American Medical Directors Association (JAMDA).
“[SNFists] can be those working full-time, employed by a nursing home, or someone who is working for a medical management company,” said Dr. Hye-Young Jung, associate professor of population health sciences at Weill Cornell Medical College and lead author for the JAMDA study. “It’s not so much if they’re employed by the nursing home or not.”
There are more than 6,000 SNFists practicing in nursing homes as of 2017 – Jung and other colleagues are working on parsing data from 2019 to further define the SNFist role, with other studies in the works.
The big challenge for proponents of the SNFist, DiRezze said, has centered around reshaping how those within the industry and on the outside have viewed medical management in a nursing home.
“This industry has not had great physician advocates and has not had great medical directors for decades,” noted DiRezze. “The amount of work that needs to be done and the amount of just revamping from a medical management perspective is endless, and we’re just touching the tip of the iceberg.”
SNFists seek to change an industry from a medical management perspective that has not been changed for “quite some time,” explained DiRezze.
The SNFist defined
The number of SNFists has increased 48% between 2014 and 2017, the JAMDA study found, but the role still doesn’t have a standard assigned definition. Such a definition would usually be given by the Center for Medicare & Medicaid Services (CMS).
That’s despite CMS and medical literature using the SNFist term. More responsibilities that fall under the role need reimbursement codes too, JAMDA authors said, in order to clearly tie SNFist care to outcomes as the post-acute care setting takes on higher acuity patients.
There are “a ton” of services that currently aren’t getting reimbursed, including services tied to the SNFist role, DiRezze said.
There simply aren’t enough funds or resources to compensate the SNFist’s administrative work alone, DiRezze said.
“You have all of your hospital discharge paperwork, regulatory visits are reimbursed, but everything that’s associated with that, reviewing patients charts for monthly order reviews … they’re not reimbursed and there’s a ton of them,” added DiRezze.
Ultimately, it will take some time for CMS to fully immerse itself into creating reimbursement tags for the SNFist role, Jung said, since the role is just now gaining attention.
The importance of the SNFist during the pandemic cannot be overstated either, Jung said, as the wider health care industry and CMS struggle to define the role.
“[The SNFist] has not just been a clinician providing medical care – they have also served as leaders in the facility where they have to make a lot of decisions on testing, isolation, visitation policies and infection control measures,” said Jung. “These are highly important decisions that require a deep understanding of nursing home populations and then also the resources available in nursing homes.”
SNFists have provided a higher quality of care to residents compared to other physicians, according to the JAMDA study, referencing another published study in 2019 connecting the SNFist to clinical quality scores.
Two of six nursing home quality measures were improved as a result of higher physician presence, and advanced practitioner specialization according to the 2019 study.
Specifically, researchers say a 5% drop in short-stay patients on antipsychotics and 6% less patients with indwelling catheters, or catheters that are left in the body.
The SNFist role will evolve as its definition and responsibilities become more concrete, added Jung. Currently, the SNFist is defined by volume of services; Jung expects that to expand to volume of care and include competency measures.
SNFists understand the uniqueness of the nursing home setting, coupled with knowledge of state and federal regulations and training in geriatrics, she added.
“Despite the fact that the term SNFist implies only nursing home care, the definition may be expanded to include care provided to our broader population. For example, individuals receiving care in assisted living,” said Jung.
SNFist motivations and operator relationships
While DiRezze believes this sense of advocacy for the nursing home physician is not necessarily a trend in the industry, he is seeing a change in satellite organizations that provide such positions to the nursing home. Medical directorship companies have taken a stance toward quality and market disruption via advocacy.
Surprisingly, there has also been a financial upside to the SNFist role as well, with reimbursement favoring the post-acute care setting specifically in early pandemic years.
A lot of SNFists were borne from that opportunity, DiRezze said, with physicians moving outside of the hospital setting to start delivering care in the nursing home.
“We saw a plethora of sub-specialties that were trying to get into post-acute care because volume was down in inpatient, volume was down in their offices. As soon as the pandemic started weaning off, all of a sudden these groups disappeared,” added DiRezze.
Surgery specialists turned wound care providers are a good example, he said, as surgical subspecialties popped up in the post-acute care space.
Once the opportunity passed, more opportunistic physicians went back to their regular office practice, or back to the hospital, he said.
DiRezze believes operators are tired of being “passed around,” as traditional medical management companies seek to grow and eventually sell or merge with a larger entity.
He sees it as a misalignment of goals between an owner-operator and medical group, with the former seeking to build their legacy with a long-term medical group partner.
“All these facilities are really seeking is the ability to depend on a reliable physician and reliable physician service that is going to take care of them, regardless of what the staffing situation is, regardless of what the environment is, regardless of what the reimbursement is,” said DiRezze.
Operators want SNFists that take care of the residents and help facilitate quality care, while making sure administrative and regulatory support is given as well, he said.
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