American Academy of Physical Medicine and Rehabilitation Position Statement on Physiatrists' Role in Skilled Nursing Facilities

There is increasing pressure in the health care system to provide high-quality, efficient rehabilitation care to patients throughout the care continuum and especially across post-acute care (PAC) settings, including skilled nursing facilities (SNFs). The American Academy of Physical Medicine and Rehabilitation (AAPM&R) recognizes that physiatrists are the essential medical experts to provide indispensable rehabilitation leadership in SNFs. Physiatrists are uniquely suited to provide vital patient care and leadership in SNFs due to their extensive training, expertise, and commitment to achieving optimal patient outcomes and efficient health care utilization. Physiatrists focus on leading interdisciplinary rehabilitation teams through recurring team conferences and overseeing and modifying rehabilitation therapy plans of care. Physiatrists establish functional goals, manage medical care related to rehabilitation diagnoses, minimize risk of secondary complications, and work to efficiently and safely transition patients to the most appropriate care setting. Physiatric patient management in the SNF setting supports the seamless transitions of rehabilitation care across the health care continuum resulting in greater functional gains, a reduction in complications, and earlier discharge, while minimizing hospital readmissions and achieving cost savings for the health care system. Post-acute care (PAC) is care after an acute hospitalization that includes treatment in an inpatient rehabilitation facility (IRF), skilled nursing facility (SNF), long-term acute care hospital (LTACH), outpatient rehabilitation clinic, and at home with home health. Physiatrists can play a role in all these settings including determining the appropriate PAC setting for individual patients, which depends largely on their diagnosis, medical needs/comorbidities/risks, functional status, therapy needs, expected gains in function, and ability to participate in therapy. In addition, there are several important non-clinical factors to consider, including geographic availability of various types of PAC settings, patient preference for a PAC setting close to home, home accessibility, and level of caregiver assistance available at the time of discharge. The availability of funding is another important factor that influences the selection of PAC level. Traditionally, IRFs serve patients with complex medical and rehabilitation needs, requiring ongoing medical care and intensive therapy services from multiple disciplines. However, due to several factors, there are increasing restrictions on IRF admissions and pressure to reduce the overall length of stay in IRFs and acute care settings, resulting in an increasing number of medically complex patients requiring rehabilitation care in a SNF setting. Medicare goes on to define skilled services as when “the inherent complexity of a service prescribed for a patient is such that it can be performed safely and/or effectively only by or under the general supervision of skilled nursing or skilled rehabilitation personnel.”5 In addition, it is expected that the medical record shows documentation of the treatment plan, team coordination, patient goals, the patient's progress toward achieving those goals, and the ongoing need for skilled services.5 Medicare does not specify the intensity of therapy services provided in a SNF, and the attending physician is only required to see the patient once every 30 days. Because SNF regulations are frequently updated, physiatrists must consistently educate themselves regarding relevant regulatory changes. In addition, because payment policies and technologies evolve, physiatrists will be able to utilize telehealth to serve as a consulting or co-managing physician for patients in SNFs in rural locations where physiatrists may not be available to provide in-person care. Physiatrists have historically had varied levels of involvement in SNFs. However, physiatrists serve an essential role in this setting to help ensure the highest quality outcomes and the most efficient use of resources. Physiatrists positively impact patient outcomes such as length of stay, functional improvements, health care facility acquired complications, and discharge disposition, among others. Physiatrists, by virtue of their training, experience, and knowledge of rehabilitation, impairment, and function have the unique qualifications and expertise to be the leaders of their SNF rehabilitation teams. Ideally, a physiatrist in a SNF setting will serve in a consulting or co-managing physician role and will visit the patient one to three times per week, depending on the medical and rehabilitation needs of the patient. Residents in long-term care might not need to be seen every week, but rather as clinically appropriate. A physiatrist can also serve as the SNF medical director, rehabilitation medical director, and/or the attending physician in some situations. Patients receiving SNF rehabilitation level of care may not need the same frequency of physician visits as patients receiving IRF level of care,6 but their rehabilitation requires more frequent physician oversight than that mandated for primary attending physicians in SNF settings. Close communication with the primary attending physician is essential for high-quality patient care. The physiatrist should track the medical status of the patient, as well as track and document each patient's functional status, thereby helping to demonstrate progress toward goals and identifying and attempting to mitigate and/or remove barriers to reaching functional goals. Physiatrists also provide medical services such as treatment of spasticity or pain that is limiting functional gains, and they can make recommendations for further medical evaluation and treatment. When clinically appropriate, they additionally identify and prescribe adaptive or assistive devices for safety and to further facilitate function. When applicable, physiatrists in SNFs can educate physicians in training regarding caring for rehabilitation patients in this care setting. To expand the role of physiatrists in SNF settings, it is necessary to educate SNF staff on all aspects of the rehabilitation model of care with which they may not be familiar. The rehabilitation model focuses on setting realistic functional goals and utilizing an evidence-based model for rehabilitation treatment, which incorporates the expectations and needs of the patients and caregivers. It requires coordinated, physician-led rehabilitation treatment that includes weekly team meetings to discuss each patient's functional status, barriers to discharge, expected length of stay, and other factors. As the leader of the SNF rehabilitation team, the physiatrist will set short- and long-term functional goals for the patient and closely monitor their progress while addressing barriers to achieving these goals as they arise. Finally, the physiatrist will also set the discharge goals and will work to manage the patient stay and facilitate the transition to the next setting in an appropriate and timely manner. This may include communication with the community care medical team on discharge from the SNF, which will strengthen care transitions and support the continuum of rehabilitative care into the community. Physiatrists must also work with the SNF administration, nursing, and therapy leadership to monitor the quality of rehabilitative care in the SNF, promote performance improvement, and work with funding agencies to determine the appropriate level of care. Because advanced practice providers (APPs) are increasingly involved in the care patients receive in SNFs, physiatrists play a critical role in ensuring that APPs are properly trained and appropriately supervised in the provision of rehabilitation care. This collaborative relationship will enhance the ability of physiatrists to consistently provide more complex patient care and to serve in leadership roles suited to their level of expertise. For further details on specific clinical and administrative responsibilities, AAPM&R provides an accompanying Job Description for Physiatrists in SNFs that can be found on the AAPM&R website.7 This AAPM&R Position Statement is intended to provide general information to physiatrists and is designed to complement advocacy efforts with payers and policymakers at the federal, state, and regional levels. The statement should never be relied on as a substitute for proper assessment with respect to the specific circumstances of each case a physiatrist encounters and the needs of each patient. This AAPM&R statement has been prepared with the information available at the time of its publication. Each physiatrist must have access to timely relevant information, research, or other material that may have been published or become available subsequently. Dr John discloses support for attending meetings and/or travel, Encompass Health for National Medical Director's Meeting; ABPMR; Vice Chair on Board of Directors. Melanie Dolak and Britinia Johnson are AAPM&R employees. Dr Grover reports support for attending meetings and/or travel, AAPM&R support for meeting travel for QPPR Committee Meeting; Chair; Limb Care Networking Group, American Congress of Rehabilitation Medicine; Scientific and Medical Advisory Committee member, Amputee Coalition; Programmatic review panel member, Orthotics & Prosthetics Outcomes Program, Department Of Defense - Congressionally Directed Medical Research Programs; Member at Large, Quality, Practice, Policy & Research (QPPR) Committee, American Academy of Physical Medicine and Rehabilitation. Dr Patel reports stock in Integrated Rehab Consultants. Dr Smith is Vice President, Clinical Care for Light year Health (healthcare company that provides PMR services to skilled nursing facilities). All other authors have nothing to disclose. The Position Statement on Physiatrists' Role in Skilled Nursing Facilities was crafted by the American Academy of Physical Medicine and Rehabilitation (AAPM&R) Skilled Nursing Facilities (SNF) Workgroup of the Quality, Practice, Policy, and Research Committee (QPPR). The Board of Governors approved the Position Statement in September of 2022. This document did not undergo standard Journal peer review. Physiatrists currently practicing in SNFs served as peer reviewers for the Position Statement. The peer reviewers are as follows: