Practice makes perfect often applies to surgery, where quality tends to rise with greater numbers of patients. But the same doesn’t hold in nursing homes. Data from more than 77,000 clinicians show that the number of patients a doctor or nurse practitioner sees in nursing homes does not affect whether these older residents avoid hospital readmissions and other problems.

More than 1.2 million people live in nursing homes, and demand for care in these facilities is expected to rise.  A new clinical specialty, focused on providing care in skilled nursing facilities, has emerged, called SNFists. LDI Senior Fellow Kira Ryskina previously found that nursing homes with these specialists increased the number of post-acute care patients they treated without a rise in rehospitalization rates, an important quality measure.

Building on that work, the researchers analyzed 2012–2019 Medicare data from 77,732 clinicians to explore whether the number of patients these clinicians treated, or the panel size, affected key patient outcomes. They found that the number of patients nursing home doctors or advanced practitioners care for did not affect patient outcomes, including hospital readmissions, the likelihood of returning home successfully, or improvements in function after post-acute care.

This question matters because many clinicians who see patients in nursing homes also practice in other settings and see only a small number of nursing home patients each year. More than half of the clinician workforce in nursing homes treats fewer than 10 patients per year.

We spoke with Ryskina about her research on nursing home physicians’ caseload and patient outcomes, and how her work affects care and policy.

What motivated you to compare the outcomes of nursing home clinicians with high- and low- patient panel size? 

Ryskina: We were working on a larger research project to compare patient outcomes under the care of SNFists – physicians and nurse practitioners who focus their practice in nursing homes—versus traditional clinicians who see patients in other settings (e.g., hospital, clinic) as well as in nursing home. During that work, we found that patient caseloads varied dramatically among nursing home physicians. In some health care settings, such as certain surgical procedures, low case volume is associated with worse outcomes. We wanted to know if a small panel size for nursing home physicians and nurse practitioners (or physician assistants) was associated with worse outcomes as well.  

What was the most exciting finding in this comparison of clinicians who care for many vs. a few patients in skilled nursing facilities?

Ryskina: The findings were null. Nursing home physician or advanced practitioner panel size was not associated with higher rates of rehospitalization, lower rates of successful discharge to the community, or lower rates of functional improvement at discharge from post-acute care in the nursing home.  In other words, clinicians with small volumes of nursing home patients had similar outcomes to those of large-volume physicians. This is reassuring since we need more physicians and advanced practitioners who care for nursing home patients.

What limitations of the study should readers be aware of?

Ryskina: The main limitation is that this was a retrospective, observational study, so there is a chance that other differences in practice between high- and low-volume clinicians affected the outcomes. There might have been unobserved differences between the patients of high and low volume clinicians that negated the positive effects of high-volume clinicians, for example. 

What are the implications of the findings regarding clinicians who work in nursing homes? 

Ryskina: I see two main implications: (1) skilled nursing facility patients and nursing homes concerned about physician care quality can rest assured that physician panel size is not a factor in outcomes; (2) policymakers and payers who want to improve physician care quality in skilled nursing facilities can focus their efforts on interventions other than clinician volume.

Where are you going next with your research to improve nursing home care? 

Ryskina: I’m interested in improving the quality of physician and advanced practitioner care in skilled nursing facilities and am examining all aspects of this type of care. We recently looked at whether patients with Alzheimer’s disease and related dementias had better outcomes in skilled nursing facilities when their care was managed by SNFists. We found that these patients cared for by skilled nursing facility specialists had similar functional status recovery, discharge, and length of stay as those cared for by other, less specialized clinicians. We are currently looking at other aspects of physician skilled nursing facility practice, such as the degree of collaboration between physicians and nurse practitioners. 

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The study, “Clinician Volume and Outcomes Among Patients Admitted to Nursing Homes for Postacute Care,” was published August 15, 2025 by Brandi Peacock, Seiyoun Kim, Ziwei Pan, Paul Katz, Hye-Young Jung, and Kira Ryskina.

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