Patients who leave the hospital and enter a skilled nursing facility (SNF) are usually in need of complex care, and a substantial number return to the hospital within 30 days. An interdisciplinary team of physicians, nurses, physical therapists, and other clinicians directs SNF patient care, but the timing of when patients first see the physician after admission to SNF varies. One in 10 patients never see a physician during their SNF stay, and those patients are far more likely to return to a hospital or die, according to 2019 research by LDI Senior Fellow Kira Ryskina and colleagues.

In a recently published study, Ryskina pushed further, exploring the link between a patient’s prognosis when admitted to a SNF and the timing of physician or advanced practice provider (APP) visits with later rehospitalization risk.

What they found was surprising. Sicker patients were not seen sooner based on their prognosis. In addition, patients who were seen sooner had a lower chance of returning to the hospital regardless of prognosis.

Medicare regulations allow this variation in the time to first visit. They require that an interdisciplinary care team of facility staff and a physician develop an individualized care plan within 14 days of admission. However, the first physician visit is not required until much later—within 30 days of admission. 

We discussed these findings with Dr. Ryskina.

You found patients seen sooner after SNF admission were less likely to be rehospitalized. What is most significant about these findings?

Ryskina: One might expect that more medically complex patients – those with a higher risk of readmission to the hospital – would be seen by a physician or nurse practitioner (NP) sooner after transfer to a SNF. However, that’s not what we saw in our data. Anecdotally, we’ve heard of cases where delays in seeing a physician after SNF admission resulted in rehospitalization. In this study, we measured the risk of rehospitalization by time-to-physician visit and found the risk increased from 3% to as much as 35% for each additional day that a patient waited to be seen.

What contributes to timing differences for initial physician or advanced practice provider visits for patients newly admitted to SNFs?

Ryskina: We know from our other work that many SNF physicians split their time between other roles, including seeing patients in another hospital or clinic, so they may not always make it to the SNF when a patient is admitted. Their visit schedule may be set in advance or depend on day-to-day availability.

Are there different levels of staffing at SNFs and how much does that contribute to timely initial medical evaluations?

Ryskina: Few SNFs can staff full-time physicians or NPs. Physician or NP visits to SNFs vary widely – from daily visits to monthly or even less frequently scheduled visits. In our ongoing work, we are interviewing staff in SNFs across the country to understand how direct care staff and administrators manage physician “staffing” in SNFs.

How can you ensure patients are evaluated in a timely way when they are admitted to SNFs?

Ryskina: The regulatory landscape, reimbursement, educational efforts, and organizational practices related to physician and NP practice in SNFs are outdated and do not address patient needs. For example, existing mandates limit NPs’ ability to perform some of the required assessments of SNF patients. Payers underinvest in remote care options, limiting patient access to only local providers willing to commute to SNFs to see patients in person. Also, training in SNF-based care for physicians remains inadequate – for instance, internal medicine residency programs virtually ignore this practice setting.  

Were there aspects or variables that you were unable to explore?

Ryskina: In this observational secondary data analysis, we couldn’t tell why some patients were seen later than others. We plan to explore this in future work.

Are there areas for future research?

Ryskina: The number of NPs practicing in SNFs more than doubled over the past decade while the number of physicians stayed about the same. Physician-NP co-management models may improve patient outcomes, but little is known about how physicians and NPs collaborate in this setting. Moreover, the current regulatory framework that mandates physicians to conduct certain visits needs to be updated to reflect these workforce trends.

How do these findings contribute to improving care in post-acute settings?

Ryskina: Patient and caregiver experience is affected by their access to SNF physicians or NPs. We know this from a prior analysis of Yelp reviews of SNFs. Timely access to a physician or NP may improve patient care experience and family/caregiver satisfaction with SNF care.

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The study, “Association Between Timing of Clinical Evaluation by a Physician or Advanced Practitioner and Risk of Rehospitalization in Older Adults Admitted to a Skilled Nursing Facility Following Hospitalization: A Cohort Study,” was published in the December 2023 issue of the Journal of the American Medical Directors Association. Authors include Kira L. Ryskina, Zhi Geng, Sridharan Raghavan, Kimberly J. Waddell, and Robert E. Burke.

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