How to Evaluate a Rounding Group: 7 Key Questions SNF Administrators Should Ask
Working with a physician rounding group can allow a skilled nursing facility to provide higher quality of care much more efficiently. However, the quality and level of service provided by different rounding groups can vary widely.
How can facility administrators tell the difference?
Answering this question can be a challenge for various reasons, most commonly due to experience, or lack thereof. SNF administrators who are new to their roles, or who work at smaller facilities, may have only worked with a handful of rounding groups in their career. Due to this limited experience, they may not know how to differentiate between a diligent, highly effective rounding group versus one that provides a less than optimum level of care.
On the other hand, experienced administrators at larger facilities often work and interact with a large number of different rounding groups over the years. Drawing on this experience allows them to differentiate between more effective groups versus those who are less effective.
To write this article, we spoke with several highly experienced senior SNF administrators, and also drew on our own experience providing care in more than 40 different facilities. We identified seven key questions to help SNF administrators evaluate a rounding group. If possible, it’s certainly better to evaluate a group before signing a contract. But while you can use these seven questions to see the substance behind a sales pitch, they will also be useful to assess the level of service provided by groups currently working in your facility.
1. Does the group follow basic practices to ensure clinical quality?
The number one question to ask about any rounding group is, what does the group do to ensure they provide quality care to residents?
To a great extent, this comes down to the basics.
Seeing patients on a schedule at regular predictable times
Seeing patients on a schedule, and following that schedule, might seem like the simplest thing in the world. But this simple practice affects all areas of the SNF in positive ways.
For starters, residents know what to expect. Again, it may sound simplistic, but for SNF residents, having a predictable schedule can greatly increase the feeling of comfort and of being “at home”. By contrast, having a physician come at an unscheduled or unpredictable time can make residents feel like they’re unimportant, even an afterthought.
Studies have shown that when physicians and nurses make rounds on a schedule, quality of care improves. Following a predictable schedule helps staff to consistently meet patients’ needs, ensure safety, reduce the occurrence of preventable events, and take proactive steps to address problems before they occur. All of this contributes to improved patient satisfaction, better communication with patients, and better outcomes overall.
Establishing and adhering to a schedule requires support at all levels, from senior leadership on down. The rounding group should take an organized and methodical approach to scheduling, coordinating with SNF staff and administration as appropriate.
If you’re considering working with a rounding group, make sure to ask about their scheduling practices, how they establish routines, and so forth. Pay close attention to their answers, and try to discern if scheduling is truly a priority for the group at every level. If there are any physicians that provide services in your facility on irregular or unpredictable schedules, consider how you might establish something more consistent.
Seeing patients in a structured manner
Conducting appointments in a structured manner is closely related to establishing a consistent schedule. Once again, studies have found significant improvements in residents’ quality of life when caregivers follow a consistent, individualized assessment and care planning system. Such a system also allows for a higher level of accountability within your facility’s management structure.
By contrast, physicians who don’t follow a consistent structure in their appointments tend to make residents feel less secure. This may lead to a perception of lower quality of care, even in cases where clinical outcomes are the same.
If a rounding group is going to provide consistent, structured care, the group management needs to make it a priority. Make sure to discuss structured care with any groups that currently provide care in your facility, or that may do so in the future, and pay close attention to how they approach the issue. It’s important that all stakeholders are on the same page.
2. Does the group prioritize data and quality metrics?
The standards by which skilled nursing facilities are evaluated get more detailed and more granular every year. Regulators, payers, hospitals, and others increasingly look at very specific data to evaluate a facility, including outcome metrics, quality metrics, ratings, and beyond.
There are currently 12 metrics that SNF’s must report publicly, with more on the way. In particular, hospital systems and health care administrators are increasingly using these metrics to create preferred networks of referral partners for their patients. Creating such a referral network of SNF partners is a rigorous process that hinges mostly on data analysis. Administrators look closely at many types of data, then create directives to advise case managers and social workers as they make recommendations to patients and their families. These types of partnerships are increasingly important, and can provide a steady flow of patients to a facility. Facilities should also realize that patients and their families will likely use services like Medicare’s Can Compare tool when choosing a long-term care facility.
In short, metrics matter more than they ever have, and this trend shows no signs of slowing down. And ultimately, data is only a means to help patients and their families make informed decisions about their health and their future. That’s why it’s vital to work with a group that not only provides quality care, but also prioritizes collecting, analyzing, and reporting relevant data at every level.
3. Does the group bring hospital-level standards of care to the SNF environment?
Modern post acute care is expected to serve many of the functions that hospital care provided in the past. On the one hand, this has allowed skilled nursing facilities to fill a valuable role, providing much-needed care in a more comforting environment for patients with chronic conditions. SNF’s have been able to fill this role at a lower cost than hospitals, while increasing revenue to the facilities. The Patient-Driven Payment Model creates more opportunities for facilities to be reimbursed at a higher rate when caring for sicker patients. CMS looks closely at hospital readmission rates and awards a percentage bonus in Medicare Part A payments for facilities with low rates of hospital readmissions.
On the other hand, CMS imposes several financial penalties on facilities with high hospital readmission rates, including reduction in Medicare Part A reimbursement, as well as a requirement to keep the patient’s bed in the SNF empty for a period of time after they are transferred to the hospital. Each facility’s bonus or reduction of Medicare Part A payments is publicly reported and searchable via online tools, so successes or struggles in this area are visible to residents, families, referral partners, and others.
As regulatory agencies and Medicare increasingly expect skilled nursing facilities to care for patients who would have remained in the hospital a few years ago, it becomes ever more important for facility staff and partners to bring hospital-level standards to the SNF environment. Facilities that do this will have better outcomes in all areas, as well as taking advantage of increased revenue opportunities available in PDPM.
4. Will physicians chart directly into the facility’s EHR?
One very specific requirement for a physician rounding group, or any physician, is that they should chart directly into your facility’s electronic medical record. In the past, clinical documentation in the SNF environment was relatively simple, but under PDPM the quality of the physician’s notes has a significant effect on the facility’s reimbursement revenue. Postpayment medical review is becoming more stringent, as physicians in the SNF environment are now expected to create a real note that would meet the standards of a hospital.
Skilled nursing facilities were relatively late adopters of EHR’s, and in the past clinical documentation in the SNF environment was relatively simple. Things have changed. A well-managed group will almost certainly use scribes to assist with documentation, and will step up and adapt their procedures to address the specific procedural needs of each skilled nursing facility.
Unfortunately many doctors still haven’t adapted to the new requirements. While some physicians and rounding groups may provide services in multiple facilities that use different EHR’s, which may increase their workload. However, none of this should be your concern.
5. Does the group understand PDPM documentation and reimbursement from the facility’s perspective?
In the past, billing codes for skilled nursing facilities were very simple. There were certain diagnoses that were used very frequently, and physicians and rounding groups didn’t have to think about them much. PDPM changed that completely, and brought the SNF billing codes more in line with the rest of the medical field.
It’s worth noting, though, that PDPM doesn’t directly affect physicians and rounding groups. In most cases outside physicians are paid the same rate, regardless of how facilities are reimbursed. In other words, inadequate or incorrect documentation doesn’t necessarily affect the doctor, but it will definitely affect the facility, in the form of delayed payments, denials, or being reimbursed at lower rates than is appropriate for patients with complex issues.
For all of these reasons, it’s very important to work with a group that is highly engaged with and invested in your facility. The group needs to invest the time in training its physicians to understand how PDPM works, how to chart in a way that maximizes reimbursement, and how to be diligent and thorough enough to stay ahead of potential audits. Physicians need to understand reimbursement matrices and know the requirements of ICD-10 codes in detail, such as which codes require laterality or other secondary information.
In short, physicians must be educated on what works and what doesn’t work for PDPM, and should incorporate that understanding into their assessment of each patient. This allows your facility to be reimbursed for every assessment that applies to each patient. It’s surprisingly easy for a doctor to omit information that, while perhaps not directly relevant to a particular visit, would still lead to higher reimbursement under PDPM. A rounding group that thoroughly understands PDPM documentation, and makes documentation a priority for its physicians, will be able to maximize reimbursement for your facility.
6. Will group physicians be accessible to SNF staff and administrators?
Communication between all providers and staff is absolutely essential to quality care. Studies have found that communication between care providers in skilled nursing facilities has a substantial impact on quality of care. The central importance of communication between physicians and nurses in SNF environments has long been recognized. Communication is particularly vital during the hospital-to-SNF transition, and deficiencies in communication during this process are widely considered a major barrier to ensuring safe and effective transitions.
The above studies further clarify the importance of working with physicians who are actively engaged with your facility, and who consider themselves truly part of the SNF team. One aspect of being part of the team is meeting with the SNF staff regularly, particularly those in four key positions:
- Director of Nursing (DLM)
- Therapy supervisor
- Social worker/discharge planner.
In general, every time a physician visits a facility, he or she should meet with each one of these four people, to go through the list of patients, and discuss any issues related to each individual.
7. Are group physicians available to talk with patients and their families?
Communication between caregivers and patients’ families has a major effect on patients’ well-being, as well as the quality and outcomes of care. The quality of communication is also closely related to patients and families’ overall satisfaction with care. Furthermore, poor communication with patients is a contributing factor in a high percentage of medical errors during patient transfers.
For all of these reasons, it’s very important that physicians be available to talk with patients and their families. In our experience, facility staff are often not able to fill this role, both because they lack the authority of a physician, and because they are often stretched thin while attending to their regular duties. There’s no substitute for face-to-face time talking with a doctor. If anything, we encourage our physicians towards overcommunication. Patients and their families are much more comfortable when they feel like they have all the information, and when all their questions are answered in full, to the fullest extent possible.
We do actively encourage facilities to use technologies to help improve communication, but once again, there’s no substitute for time with a doctor. Community Physicians’ doctors will both meet with patients and families in the facility, and also call patients’ families and talk with them when appropriate. This emphasis on communication tends to lead to better customer satisfaction on the part of patients and families. This type of overcommunication can also reduce or mitigate potential liability issues for the SNF in some circumstances.
Our group has seen so many benefits from improved communication that we’ve actually gone one step further, and brought a dedicated care coordinator onto our own staff. This care coordinator is a nurse practitioner, who comes into the facility with each patient for one hour within the first few days after the patient is admitted. In most cases, the patient’s family will be present at this meeting as well. We’ve seen tremendous benefits from adding this care coordinator role, and we plan to expand it and document its benefits in the future, as we better understand how this extra emphasis on communication has affected and enhanced our overall care program.
What are the goals of evaluating a rounding group?
In some ways, each of the above questions relates to one central theme: Is the group focused on adding value?
When we first started in the SNF industry, we found that many physicians and rounding groups did the bare minimum. When we founded our group, we did so with the intention to explore the opposite paradigm: How can a rounding group add value in its relationship with skilled nursing facilities? How can we improve care, either through new and creative ideas, or through simple implementation of fundamentals?
We believe this creative, imaginative, value-focused approach is the future of care in SNF’s. Ultimately, we hope this article inspires both SNF leadership and physician rounding groups to reimagine what is possible in this field, and take concrete steps to provide consistently higher levels of service and care.