When I left my office internal medicine practice in 2005 to work full time in the SNF setting as a clinician and Medical Director, I was able to keep my previous on-call relationships with my colleagues.  However, the commitment to caring for my patients on the part of my colleagues, was a commitment to managing patient issues by phone or fax with the understanding that the ER would be the default position.  Specifically, there wasn’t a commitment to seeing patients on site for changes of condition or for seeing patients prior to being discharged to a lesser setting of care.  The latter would instead be done by facilities faxing a request for d/c home on current meds with appropriate DME and outpatient rehab referrals.  I would describe this system as working well for physician practices, but not optimally for the patient.

Since 2005, the SNF world has changed.  Our patients are much sicker, more complex, and are much more difficult to manage optimally by phone or fax.  The OIG report on the quality of nursing home care of March 2014 has triggered the first major revision of CMS expectations for nursing home care standards since 1987, which will be finalized later this year.  Through these regulations, CMS will expect much more on site assessments and care by physicians.  In addition, as bundles for joint care are rolled out in 2016 and as other linkages occur between the acute and post-acute settings, our acute hospital partners will expect on-call coverage that supports optimal patient experience of care and outcomes.

In my situation, after years of failed efforts to grow a LTC group within my company, I was able to partner with several LTC companies in my city to bring on 3 independent full time post-acute care physicians as well as with another independent provider already in the community.  Together, we formed a new on-call group that has been operational since January of 2015.  Together, we have developed shared patient care protocols and have shared best practices for managing common changes of condition and abnormal labs during the standard work week.  The goal has been to have as much patient care as possible occur during the week by the patient’s attending physician.  This has resulted in much less after hours calls for what should be handled that day or the next by the attending.  In addition, when one of us is on vacation, the work among facilities is divided up so that facilities know who’s in charge and the covering physician knows they are responsible for on-site care at that facility for all the services the attending would have performed if they were present.

I just returned from a 2 week vacation abroad and was pleased to return and find my patients well cared for with discharge summaries completed at the time of discharge and email sign out on details of unresolved clinical issues.  On my first day back to work, I was able to see those patients and then focus on new work.

This team approach to providing 24/7 patient centered care is what CALTCM and the new CALTCM SNF 2.0 project recommend.  I and CALTCM look forward to hearing your ideas about how Physician/NP/PA call coverage is changing to better serve our patients.