Growth of Skilled Nursing Facility Specialists: Navigating Between What Is Ideal and What Is Practical

In an ideal world, primary care physicians would follow their patients from the office to the hospital and to the nursing home. This would improve continuity of care and increase the chances that the patients’ preferences, generally better known by the primary care clinician than a new clinician, are respected; additional specialty referrals can always be obtained when needed.

However, in the real world, primary care physicians are seeing office patients every 20 minutes, following up on laboratory tests, reconciling medications, filling out forms, returning telephone calls, and often leading a team of other clinicians. In areas where there are many hospitals and/or nursing homes, a primary care physician might have patients in multiple locations, making daily visits unfeasible.

Indeed, the difficulty of primary care physicians rounding frequently and in a timely way on their hospitalized patients has spurred a national movement toward the use of hospitalists. Although the jury is still out on whether care by hospitalists results in better outcomes, the growth of hospitalists continues because of the challenges of primary care physicians having the time to travel to and round on their hospitalized patients.

It is not surprising that similar issues would arise in the care of patients in nursing homes. Although they may not be acutely ill, nursing home residents often have multiple problems and appropriate interventions might prevent rehospitalization (eg, adjustment of diuretic treatment to prevent respiratory distress) and/or improve the quality of care (eg, discontinuing use of unnecessary medications begun in the hospital). If it were possible for primary care physicians to see their patients in the nursing home, many issues, especially those involving end-of-life care, might be better handled because the primary care physician would more likely to know patient preferences.

However, if primary care physicians cannot get to the nursing home, having other clinicians in the nursing homes who are familiar with the needs of chronically ill patients is likely to improve their care. The absolute increases in health care professionals working exclusively in skilled nursing facilities (SNFists) reported by Teno and colleagues¹ is small but may represent a practical solution to providing medical care to nursing home residents.

Corresponding Author: Mitchell H. Katz, MD, Los Angeles County Department of Health Services, 313 N Figueroa St, Room 912, Los Angeles, CA 90012 (mkatz@dhs.lacounty.gov).

Conflict of Interest Disclosures: None reported.