SNFist: A Trending Inpatient Medical Specialty

A SNFist, SNF-ist, or SNFologist is a physician who typically cares for senior or recovering patients in step down or Skilled Nursing Facilities (SNFs) and is defined by having an average of 80-90% of their billing claims based on nursing home care. Like hospitalists, who see patients in a variety of possible acute care, subacute care, and long term care facilities, SNFists can treat patients in a variety of medical settings including inpatient rehab facilities (IRFs), long-term acute care hospitals (LTACHs), conventional SNFs, and other step down and nursing centers.

• The term SNFist is roughly 6 years old, originating as a role published in the Journal of American Medical Directors (JAMDA) though the Center for Medicare and Medicaid Services (CMS) hasn’t provided a standard definition of the role.

The primary specialties of a SNFist are physical medicine and rehabilitation (PM&R or Physiatry), geriatric medicine, geriatric psychiatry, and palliative care though a variety of specialists may also come to associated facilities as needed to provide specialized treatment, diagnostics, and rounding care.

• Multiple scientific studies (referenced at the end of the article) emphasize the importance of the SNFist in helping reduce preventable hospital readmission rates as well as providing significantly better patient outcomes when compared to generalist physicians in the same settings.

While there is some level of interchangeability in certain contexts because of the similarity of rounding structures and overlap of categorical responsibilities, there are definitely some key differences. 

The first is primary setting. While SNFists typically operate out of facilities (facility-based medicine), hospitalists typically work out of hospitals (hospital-based medicine). While there is some overlap in the middle, hospitalists tend to work in acute care settings while SNFists work in post-acute care settings. 

The second key difference that stands out is the medical specialty. Hospitalists and SNFist are general umbrella terms for multiple specialties. But while SNFists are one of only 3 or so possible specialties, the hospitalist umbrella covers a double digit number of possible specialties.

This includes internal medicine, critical care, urgent care, emergency medicine, hospital psychiatry, inpatient infectious disease, hospital cardiology, inpatient pulmonology, hospital endocrinology, inpatient gastroenterology, and dozens of other specialties and sub-specialties who provide the majority of their patient encounters in acute care hospital settings.  

Much like hospitalists, SNFists are contracted to work at the skilled nursing facilities (and other settings) rather than being employees. This means that they require either a billing team or an outsourced billing service to process their financial claims and ensure they are properly reimbursed for all the services they render.

Being primarily facility-based, an in-house billing team is harder and costlier to pull off than a traditional medical office-based practice. This is why more than 8 out of 10 SNFists employ an outsourced billing company to handle their claim processing and insurance reimbursement needs.

From a software standpoint, SNFists are very similar to hospitalists in that they are required to chart in the facilities EHR of legal record. Unlike a hospitalist, where the hospital could be using any of a dozen major options or a dozen other small options, skilled nursing facilities are overwhelmingly in the hands of two primary EHR options: PointClickCare (PCC) which has between a 70-80% market share or MatrixCare, which now that it has acquired SigmaCare, has majority control of the remaining 20-30%.

From a needs perspective, that means SNFists require software systems that integrate seamlessly into PCC and/or MatrixCare depending on what the facilities they round in use.

There are several charge capture, practice management, and billing software systems that partner with PCC and/or MatrixCare to provide integrated solutions.

But Claimocity holds the only premier integration partnership which allows them to pull and push progress notes directly into the EHR system. The coded data flow enables the census to stream right from the facility and all the data entered on any connected device to update in real time on both systems. 

This advanced level of connection is a huge timesaver as new patient data flows directly to the app without any manual or redundant data entry, progress notes in the charge capture workflow flow directly into the EHR note section of the chart, all the chart info is available at a glance, and both billing and charting can be completed at the same time using a single series of steps at the point of care without spending hours later catching up. 

Many SNFist practices pay for a secondary EHR that they do their charting in before transferring the data into the EHR of note in the facility. This allows the practice to provide quality assurance and control as well as increase the ease of use for the physicians in their practice. 

The downside is not only a significant monthly cost, but a huge increase in data loss or exposure risk and liability, as well as an increased burden to transfer the data and a large amount of redundancy.

A secondary EHR adds a level of potential human error as well as introduces a second system to the mix, creating opportunities for data losses, incomplete transfers, mix ups, errors, and security issues. The facility owns the EHR of legal record, it is the only one that matters for liability purposes, so anything that doesn’t transfer correctly or doesn’t make it becomes a big problem. 

Notable data-science trends and forecasts show that SNFists are in the unique position to impact key variables that impact hospital readmission rates, especially in older patients with multiple comorbidities at risk for readmission. 

Prior data shows that a quarter of hospital admissions could have been avoided if seniors received better care in the home, outpatient setting, skilled nursing, or other related care facility. 

By caring for senior at risk patients outside of the hospital setting, SNFists can prevent a percentage of unnecessary readmissions for issues such as urinary tract infections, pneumonia, and other serious but treatable or addressable conditions. 

Where an ambulatory care physician will see a patient in the nursing home once a month at most, a SNFist will average an encounter with that patient on the daily or weekly. 

There is a growing shift in nursing homes toward higher acuity patients.

This will provide a growing need for SNF focused specialist physicians who will benefit from the shifting focus while not having to deal with the high levels of bureaucracy and red tape that comes with medical committees and decision trees in corporate medicine and high acuity units (HAU) in hospitals.

Instead, they will be able to take on a greater role in treating higher acuity patients within the scope of the protocols and processes of that facility, which is provider and patient-oriented in focus.

There have been several scientific studies conducted on SNF physicians and their role in providing care to patients in skilled nursing facilities. Here are a few examples:

• Journal of the American Medical Directors Association (2016): Researchers examined the impact of SNF physicians on hospital readmissions among Medicare beneficiaries. The study found that patients who received care from an SNF physician had a lower risk of hospital readmission compared to those who did not receive care from an SNF physician.
• Journal of the American Geriatrics Society (2019): Examining the role of SNF physicians in managing pain in patients with dementia. The study found that SNF physicians played a crucial role in assessing and managing pain in these patients, which led to improved quality of life and reduced caregiver burden.
• American Medical Directors Association (2020): This study examined the impact of SNF physicians on the use of antipsychotic medications in patients with dementia. The study found that SNF physicians were able to reduce the use of these medications, which are associated with increased risk of adverse events and mortality, by providing alternative treatments and addressing underlying causes of behavioral symptoms.
• Journal of American Medical Directors (2015): This study surveyed medical directors of skilled nursing facilities and found that having a dedicated SNFist led to improved patient outcomes and reduced hospital readmissions.
• American Geriatric Society (2016): In an article titled “Outcomes of Skilled Nursing Facility Residents Treated by a Geriatrician or Generalist Physician: A Propensity Score Analysis,” this study compared outcomes for skilled nursing facility residents treated by either a geriatrician or a generalist physician and found that those treated by a geriatrician had better outcomes, including lower hospital readmission rates and higher functional independence.
• JAMDA (2017): In an article titled “The Skilled Nursing Facilityist: A Model for Post-Acute Care Coordination” the SNFist model of care and its benefits was explored, including improved communication and coordination of care between providers, reduced hospital readmissions, and improved patient outcomes.
• Journal of Hospital Medicine (2018): A scientific study called the “Impact of Skilled Nursing Facilityists on Hospital Readmissions for Patients Receiving Post-Acute Care” found that skilled nursing facilities with dedicated SNFists had lower hospital readmission rates for patients receiving post-acute care.

Overall, these studies suggest that SNF physicians play a critical role in improved outcomes and reduced healthcare costs.