In "silver tsunami," physician-led teams optimize postacute care

Something has to change. The U.S. population, as a whole, is older than it has ever been, with people 65 and up accounting for 18% of the population and growing faster than any other age group. Meanwhile, the physician shortage—which the U.S. Health Resources and Services Administration estimates exceeds 19,000 doctors—is already a pressing reality for millions of patients, and is likely to get worse before it gets better.

Fortunately, things are changing, especially in postacute care. Medrina, the largest group of physiatrists within postacute rehabilitation settings, is taking a physician-led, team-based care approach to providing physical medicine and rehabilitation care with the help of nonphysician team members such as nurse practitioners (NPs), physician assistants (PAs), occupational therapists and physical therapists.

"As we get into the silver tsunami, with a large percentage of our population needing some sort of senior care, we're going to have to use physician assistants and nurse practitioners to deliver care properly because there's not enough physicians to take care of that number of patients," said Amish Patel, DO, Medrina’s founder and CEO.

Medrina is part of the AMA Health System Membership Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

The physiatry-owned, Chicago-based company was founded in 2010 as Integrated Rehab Consultants, shortly after the Centers for Medicare & Medicaid Services implemented a new rule cutting eligibility for inpatient hospital rehabilitation.

"Prior to that, if you were, say, a surgeon, you knew what was going on with your patients—you could just visit them in the rehab unit," Dr. Patel said. "After the rule change, patients started going to skilled nursing facilities in large numbers, so having programs in those facilities meant a lot more because referring physicians were losing eyes and ears on those patients."

What physiatry-led care looks like

Medrina has some 900 physicians and other health professionals at work. Roughly 60% are physicians, and most of these are physiatrists. But the company also has internists, cardiologists and pulmonologists. They work in more than 1,300 skilled nursing facilities and 60 hospitals in 40 states.

"Where we can—meaning in almost all major and midsized markets—the physician is going to be boots on the ground. They might round every other time, alternating with an NP or a PA," Dr. Patel said. "When you get into the more rural markets—for example, 50 or 100 miles outside of a market like Chicago, which is where I'm based, or a couple hundred miles north of Miami, which is my second home—we use physician assistants or nurse practitioners, but the doctor is always aware of what’s going on and guiding care."

To ensure quality of care at those rural sites, physicians use the EHR to remotely view patient charts and also make on-site visits on at least a quarterly basis

"We're able to jump on video calls with the facilities to take part in their utilization-review meetings, talk with payers about how patients are progressing, and provide clinical oversight of the NPs and PAs so that if they have questions in more complex cases, we're available every day," said Matthew Cowling, DO, Medrina’s chief clinical officer. Dr. Cowling practices in rural Tennessee and Wisconsin.

In addition, Medrina gives its nurse practitioners and physician assistants robust training and supervision.

"When we onboard a new provider, they go through our Medrina 360 learning-management system, which provides extensive clinical education in physiatry videos and lectures created by board certified physiatrists," Dr. Cowling said, adding that monthly webinars provide ongoing training. We’re constantly monitoring performance—including documentation quality, clinical decision-making, and appropriateness of physician consultation to ensure consistent standards."

The AMA is fighting scope creep, defending the practice of medicine against scope of practice expansions that threaten patient safety and undermine physician-led, team-based care.

The American Academy of Physical Medicine and Rehabilitation (AAPM&R) has a number of position statements addressing scope of practice. The academy’s position is that "physiatry-led, patient-centered, team-based care is the best approach to providing optimized rehabilitation care for patients." AAPM&R also strongly opposes the independent practice of nonphysician providers in rehabilitation care and says that such professionals "must work closely with a physiatrist who serves in a supervisory role."

AAPM&R also is strongly opposed to expanding nonphysician providers’ role to replace that "of rehabilitation physicians in inpatient rehabilitation settings and all practice settings due to the disparity in physician training" and the training of nonphysician providers.

Personal, even if not in person

Besides rounding on patients for pain management and to make sure they are improving functionally, one of Medrina’s key performance goals is preventing hospital readmissions.

"That's a huge part of what we do—not just discharging patients, but discharging patients safely to home," Dr. Patel said.

Still, for some patients, discharge is way off in the future, and optimizing their care requires a mix of strong clinical knowledge, consistent communication and administrative savvy.

"Take our classic patient with a stroke who's now in a skilled nursing facility. That patient has a complex rehabilitation course—stroke recovery can take up to a year," Dr. Cowling said. "They may have speech barriers, hemiplegia, spasticity, or post-stroke shoulder pain. If the patient isn’t progressing as expected, the NP or PA would contact the physician to reassess the diagnosis or treatment plan. In cases such as neuropathic shoulder pain, if the physician is on site, they can perform a suprascapular nerve block or alternative procedure if indicated."

If that is not the case, then the physician can guide the nonphysician provider "on medication management and appropriate next steps, including referrals and coordination with therapy."

The physician also needs to be in ongoing contact with the rehabilitation director or nursing director to determine how the patient is progressing.

"Let's say that same patient is going to be cut by insurance because they're failing to progress in therapy. The physician can help by optimizing the rehabilitation plan of care to give that patient the best opportunity for functional improvement and talk to the payer about an extension. That patient may have more potential—they just need the correct intervention to get home safely," he said.

Accountability is key

Despite the scale of Medrina’s operations, the company’s success is largely a result of customizing its programming for each site.

"They say if you've seen one inpatient rehab facility, you've seen all inpatient rehab facilities, because inpatient rehab is standardized. But If you've seen one skilled nursing facility, you've seen only one skilled nursing facility. They can be very different from one to the next," Dr. Patel said.

This requires genuine, hands-on physician leadership, Dr. Patel said, noting that for ethical and legal reasons it is essential for there to be a reasonable ratio of physicians to nonphysician providers for there to be meaningful and effective supervision of rehabilitation medicine care.

"Physician assistants and nurse practitioners—they do an amazing job," he said. "but their training has led them to be overseen by a physician." Because so few nonphysician providers get exposure to either physiatry or postacute care, education and training are paramount for success."