Is there a sea change in LTPAC market for attending physicians?September 18th, 2013 by
Each of us knows fall is coming. Deciding when it arrived is a personal perception.
Since the passage of the Patient Protection and Affordable Care Act (PPACA), we’ve predicted that the role of LTC physicians was destined to change. That legislation, paired with the HITECH Act, casts primary care physicians and nurse practitioners in the role of “quarterback” for the patient’s care team. PCP workloads would increase in every setting. The days of a physician following patients in multiple settings would stop making sense – both for the physician and the provider setting.
Like fall, the change in a market is gradual, usually determined by a series of personal observations. Events over the past two weeks may foretell the new role of the physician is finally apparent to the LTC industry.
Scott Kuhlman, the COO of Extended Care Physicians, manages relations with the group’s 90 odd LTC facility customers. He is usually juggling requests from approximately 10 facilities across the state for MD/NP coverage. In a one-week period earlier this month, two significant regional networks totaling 25 nursing facilities called him with requests for service.
These networks weren’t unhappy with the skills of the MD/NP teams that delivered direct care, but decried the lack of “system thinking” at the practice level. They wanted better on-call management decisions and data exchange, and for the first time in our experience, central management wanted to discuss strategies to manage rehospitalization rates.
Scott was particularly familiar with one facility he’d visited in the past. They were served by a hospital-based medical group, and felt that hospital connection was critical to their success. He queried the executive, asking what had changed. The message he heard: Rehospitalization rates now have more impact on Part A patient referrals than does a relation with hospital medical staff.
Another large chain called asking Scott if the physician group could expand to an adjoining state – a rural facility had “run out” of local physicians. The last MD who provided coverage was leaving LTC medicine, and there were no replacements. Even with ECP’s connections and resources, to date it is impossible to find a replacement.
Community-based PCPs and weakly organized LTC practices are pulling back on LTC care. There may be specific geographic locations where an overabundance of physicians exists, but they seem to be shrinking. Across a broad spectrum of LTC practices we know, staffing is the No. 1 challenge.
This is unsettling. How do LTC medical groups employ, train and deploy high-quality staff to credibly manage this growing demand?
Here’s my analysis. The greatest challenge isn’t finding staff interested in working in LTC settings; the problem is retaining them. The prime complaint I hear from LTC medical groups is “how darned difficult” it is to get their job done. The workflow thwarts productivity – which still fuels provider compensation. That directly affects retention. Here is a list of specifics:
- Facilities have high turnover, so there isn’t a reliable nurse to use for collaboration.
- The “daily problem list” is incomplete, so checking with staff is critical to avoid missing a pressing problem.
- Patients are difficult to locate, as is their chart data (either paper or electronic).
- Getting the patient to a private location for the “encounter” wastes lots of time.
- At the end of rounds, where do you find the right nurse to discuss orders, etc.?
Some facilities are solving this problem by hiring staff directly, others are contracting for supplemental NP coverage to support beleaguered community physicians. Both of these are valid strategies, but they simply postpone the problem – there is going to be a significant shortage of primary care staff to work in LTPAC settings.
LTC clinician workflow is the overarching issue regardless of what staffing strategy is employed.
Facilities, medical groups and LTC pharmacies are all in this together. Without better collaboration, it will become increasingly difficult to attract and retain quality medical staff. Without a competent staff, both quality and efficiency will suffer.
It was heartening to see regional LTC facility groups are beginning to focus on the need for systematic planning and coordination. It is completely possible to make the LTC MD/NP job more rewarding, and allow practices to shorten the employment, training and deployment cycle. This is the only long-term solution for deploying adequate numbers of competent staff.
I’ll be presenting an expanded discussion on this and related topics during the 2013 American Health Care Association’s Convention in Phoenix (Oct. 7), the 2013 American Society of Consultant Pharmacists Annual Meeting in Seattle (Nov. 22) and the 2014 AMDA Long Term Care Medicine Meeting.