Physiatry is becoming a cornerstone of skilled nursing care in the midst of a push toward value-based reimbursement in Medicare and Medicaid. Its integration into care teams has helped improve outcomes while reducing costly hospitalizations, industry leaders said.

The rise of patient acuity has been a huge driver in the evolution of physiatry in nursing homes as well, according to Mark Parkinson, who serves on the board of directors for Illinois physiatry group Comprehensive Rehab Consultants.

Parkinson, formerly the president for the American Health Care Association and National Center for Assisted Living. (AHCA/NCAL), told Skilled Nursing News that acuity, and value-based care reimbursement, will make physiatrists indispensable in the years to come, especially as demand for functional outcomes and survey readiness grows.

“You’re going to see them rolled into the value based plans of providers. Every provider really has to think through how they are going to survive in a value based world,” said Parkinson. “In order to survive in a value based world, you have to be really good at rehospitalization, and because physiatry has such potential to help on that particular metric, I think you’re going to see physiatry playing a key role in these future value based models.”

Dr. Ahzam Afzal, co-founder and CEO of Puzzle Healthcare, also in Illinois, said physiatry is becoming less of a side consult service and more of a critical clinical and regulatory asset, echoing Parkinson’s connections between value-based care, acuity and physiatry.

“Physiatry brings a layer of clinical oversight that’s uniquely focused on function safety and long term recovery, and not just stabilization,” said Afzal. Physiatrists determine whether a patient is functionally ready to discharge, and if their therapy goals are realistic, he said. They also look for unaddressed pain, spasticity or cognitive decline that nursing or therapy alone might miss.

And residents who once went to inpatient rehabilitation or long-term acute care facilities are now going to nursing homes, meaning more complex care than before, and in turn more of a need for physiatry, Parkinson said.

“You’ve seen a dramatic increase in the use of physiatrists over the last five to 10 years. It’s to meet the demands of acuity,” said Parkinson. “Physiatrists are able to come into a building, primarily working with the rehab population, the post-acute population, and help collaborate with the physical therapy teams.”

Puzzle has increased to 12 states in three years, while Comprehensive offers physiatry services in more than 30 states.

Safer transitions, supportive interdisciplinary teamwork, enhanced documentation, and thriving under value-based care models are further achieved with a physiatry team, added Afzal.

Evolution of how physiatrists are used

While physiatry wasn’t common in nursing homes a decade ago, an increasing number of operators are using such groups to contend with rising acuity among patients, along with shifting compliance regulations – most recently discharge and admissions requirements part of survey changes in April.

About 4,000 nursing homes out of about 15,000 in the country use physiatry groups, and that number is increasing, according to Asim Aziz, COO for Comprehensive Rehab Consultants.

Today’s physiatrists are rounding on-site during the day and are fully integrated into the care team, said Parkinson. Physiatrists are collaborating with therapists, medical directors and nursing staff within the nursing home.

The utilization of the physiatrist has changed along with the numbers seen in nursing homes, added Parkinson.

“We look at physiatry as a strategic lever for value-based care, regulatory compliance and patient experience across the full post-acute care continuum … our focus is providing early functional assessments, pain control, goal setting, real time therapy, and plan alignment to avoid any sort of under or over utilization,” said Afzal.

Ten or 15 years ago, a physiatrist would have filled the role of medical director with a whole bunch of other assignments and other tasks throughout the day. Now, physiatrists are part of a “modern” care model, Parkinson said.

“In the old days, physiatrists would come in, maybe see the patient early in the morning for just a few minutes, and then leave the building and go on to whatever their next thing was. Now they’re becoming much more part of the care team,” Parkinson added.

At the same time, physiatrists support rehabilitation goals and improve discharge planning, Parkinson said, with some follow- up post discharge to ensure a successful recovery. This trend would also help operators dealing with care transitions updates included in surveyor guidance implemented April 28.

Parkinson said he hasn’t seen physiatrists disrupt existing therapy vendors or models – it’s meant to be a collaborative service, not a replacement for therapy providers in the nursing home.

“There are multiple models to deliver therapy, and our view is that all of them can work, and bringing in a facilitator shouldn’t result in a change in either the model or who the vendors are,” said Parkinson.

Afzal, meanwhile, said nursing homes have begun to favor therapy vendors that integrate physiatry and support value-based goals. It changes how contracts are evaluated and shifts preference toward outcome-driven partners.

Physiatrists as tool for better compliance and higher reimbursement

Discharges and admissions are top of mind for operators right now considering surveyor changes recently placed – physiatrists are deeply involved in ensuring a resident meets their “maximum function,” Parkinson said, meaning the quality measures in the buildings improve and readmissions decline.

This is especially true for modern physiatry programs where the physiatrist works closely with the clinical team, where someone from the physiatry team calls the resident after discharge, usually more than once a week for 90 days.

“When you look at the utilization right now, many of the very best and most admired providers are using physiatry,” said Parkinson. “As the word of that [utilization] gets out, I think that you’ll see other people adopting physiatry.”

Moving forward, physiatry is expected to be a lifeline for nursing homes’ survival in value-based care, with CMS famously aiming to make the majority of all nursing home payments value-based by 2030.

“Right now, the Medicare rate can go up or down 2% or 3% depending upon their rehospitalization rates, and physiatry can help with that in the future, as reimbursement becomes more tied to outcomes,” added Parkinson.

Health systems and payers are watching nursing home outcomes more closely than ever, Afzal added.

“Physiatry driven programs demonstrate the commitment to post-acute recovery,” Afzal argued. “They improve relationships between nursing homes and Accountable Care Organizations (ACOs), Medicare Advantage plans. Operators become more attractive as preferred partners.”

Managed Medicaid in certain states, Parkinson said, is increasingly tying rehospitalization rates to incentive plans; it’s the first quality measure tracked for managed Medicare.

Ohio is a frontrunner here, Parkinson said, with operators able to receive additional payments on Medicaid if you’re in the top 75% of various quality measures, something that he expects to see from other states before long.