KS: You know, Toby, SilverSage is about a year and a half old but you and I have worked together for close to eight years now on the concept that has become SilverSage.  Early on, I think both of us realized that there was a need for a stronger physician presence in nursing homes.  What interested you about working full-time in a facility? TS: I think for me it actually goes pretty far back to early experiences in a nursing home with my grandparents, visiting them. Being in a nursing home was a hard time for them.  Their physician was never around.  I would always go and visit and wonder, “Where is the doctor and why isn’t he here to see my grandmother and my grandfather?”  And so, for me it stems back to that desire to have a physician provide care in a nursing facility, and allowing that interaction not only with the patient, but with the family as well. Not only that, but as a physician in practice now, looking at the volume of patients that most physicians see in the nursing home setting; and [the fact that] you need to go to several nursing homes to make it work was a discouragement to me coming out of fellowship.  I didn’t want to spend half my time driving between facilities.  And so, the concept of spending my time in the facility, with the patients, with the people who take care of the people I want to take care of, was refreshing. It really was an exciting start to what I think is going to be an amazing influence that we are going to have, nationally. KS: I agree.  We both know, and I think, post-acute and long-term care companies around the country know that there is federal and state law that says any patient who is admitted to a nursing home must have a doctor of record.  There is another law that says each nursing home must have a medical director, a physician who is the medical director of record for that facility.  But my understanding from visiting nursing homes in multiple states across the nation, is that states vary on how they interpret those laws.  One state may say that, “Yes there has to be a doctor of record, and that doctor needs to show up within 48 hours to see that patient once that patient is admitted.”  Another state may say, “As long as the doctor shows up within the first 30 days, that is good enough.” I know that about 10 years ago there were some studies that showed about 35% of patients that go to the post-acute side of the nursing home end up being re-hospitalized in 30 days or less; and well over 50% of those patients never saw a doctor once before they ended up back in the hospital.  How does that play into what we’re doing and the need for a doctor in a building from your standpoint? TS: I think one of the biggest impacts that we have by providing physicians in facilities is by seeing those patients as soon as possible when they get into the facility.  There is so much communication, documentation-wise, that is going around, everything from Medication reconciliation to poly-pharmacy. There are so many things that need to be addressed on day 1 of that patient’s visit to the nursing facility.  It’s no wonder that the bounceback rates and re-hospitalization rates are so high as of right now because there isn’t the oversight of the medical care from day 1.  Even though each state has such a different standard, SilverSage comes in and we raise the bar and put that standard at day 1.  And seeing patients within 24 hours of them being in the facility is ideal.  We want to provide that quality.  We want to provide that review of their medical history, and get their physical exam and get the information that’s needed on day 1 so that we don’t have these loopholes or these areas that weren’t addressed that are the reasons for the rehospitalization rates. KS: I do think that initially when we looked at this that we thought of rural nursing homes, outlying facilities, where it was harder to get a doctor to come. We felt that we would be able to address a need there. Our experience has been more over the last year and a half that surprisingly some nursing homes in very populated areas, inner city nursing homes even, are begging for help, because even though we thought there would be a lot more physicians in that type of setting, those physicians don’t necessarily want to spend a lot of time in the nursing home. What other types of quality outcomes have you been seeing from what we’ve been able to provide? TS: I think there are a lot of benefits from a quality standpoint.  I think the patient satisfaction is a really a big component to the effectiveness of the program. Is the physician doing what they need to do to take care of the patient?  Their satisfaction in that is number one.  And by being there and seeing them right away when they get there is of the utmost importance. Additionally, when we look at the number of medications that patients are taking, our physicians are coming in and reviewing that, and then reducing the number of unnecessary medications, everything from narcotics to anti-psychotic medications. That is improving the quality that that patient is getting.  They are having less falls.  They’re having less behavioral issues. They’re getting stronger, quicker, faster.  And they’re getting home, the place where they want to be, if they are there for short-term rehabilitation, sooner to be with their families, and sooner to get back to the life that they want to live.  The quality from that standpoint has been astronomical in most facilities. With medications, not only does the patient benefit, but the cost to the facility, itself [is reduced].  We can reduce the number of medications and the cost of those medications by being aware of what those medications are for, and what the side-effects are, and really establishing a good plan of care that is going to comprehensively treat the patient while also looking at the facility comprehensively in a way that doesn’t just address the medical needs but addresses the cost aspect too.  I think those are quality [standards] as well. KS: I really think that when it comes to reducing these medications, part of the problem with that is it’s tough to be a physician that shows up at a building once every 30 days. The nursing home hands you a list of all these patients that need to be seen; and you’re trying to fit that into your work day at the office or the hospital.  To really sit down and think about eliminating medications that the patient is on, it takes some time to understand that patient, where they are, and whether it’s safe to get rid of some of those medications.  It’s really hard on the spur of the moment to make that decision unless you know that patient.  Even just reducing a dose of a medication, if you reduce the dose, and you’re not back for 30 days you have no idea whether there’s been an effect on that patient’s behavior, their blood pressure, their medical outcomes, etc… to know whether we did the right thing or the wrong thing. You’re then relying on nursing staff. In many cases, [facilities] are pretty short staffed as far as time for nurses to evaluate patients that way while they’re giving medications out all the way down the hall and taking care of every other need that comes up. Just one more thing and that is, it seems like we [understand] what we’re bringing to patient care; but it also seems like we are impacting nursing care as well and how they give that care in facilities.  Some people say, “Well if you’re there every day the nurses are going to lose their skills.”   Are you finding that or not? TS: I think it’s just the opposite. By allowing SilverSage an opportunity to come into a facility, we’re able to educate not only the nurses in a way that allows them to do better physical exams and to do better patient care, but they’re able to train other nurses as well.  Our goal is really not to take on more responsibility with what nurses should be doing, but to help them develop their own clinical skills in a way that is going to improve the patient care throughout. KS: And I would say, to empower the nursing home and the staff to do what they need to do. TS: Exactly