Image of masked clinician and patient talking in clinic visit

The high quality of care provided by physicians who work primarily in the skilled nursing facility sector was front and center during the pandemic, but this provider specialty could use more support from the industry, medical community and policy makers, these doctors say.

Insights into these clinicians’ contributions to resident care and current constraints arose from interviews with 35 physicians who currently or previously have served as medical directors or attending physicians in nursing homes.

The study, published Thursday in JAMDA, is the first to explore perceptions of the doctors who are sometimes called “SNFists” in the nursing home industry, investigators said.

A unique practice approach

A unique practice approach helps these doctors achieve better outcomes, the doctors told investigators during structured interviews. They recounted how their ability to provide real-time oversight and immediate treatment results in optimal outcomes, including lower rates of antipsychotic use and rehospitalization, and better medication management and deprescribing.

The doctors also noted the SNFists’ in-depth understanding of the nursing facility segment, including the role of nursing staff members, state and federal regulations and resource constraints. SNFists help to fill a practice niche for the nursing home population with care for dementia, transitional and palliative care, they said. Their clinical experience enables them to address the mixture of acute conditions and chronic illness that many residents present with, they added.

Recognition of pandemic role

These doctors’ commitment to individual nursing home residents was on display during the COVID-19 pandemic, when many hospitals wouldn’t accept ill residents, investigators found. At the height of the pandemic, SNFists were often the only physicians on site due to visitor bans. They took on tasks such as providing guidance on quarantine procedures, reviews of infection control policy and regulations. Many also ran COVID-19 units. 

“I think people don’t realize that SNFists are frontline providers,” one doctor said.

Practice constraints

But there are constraints holding the practice back, contributing to spotty care quality and discouraging more physicians to join the specialty, interviewees said. These include an unclear definition of the SNFist role, loose qualifications and a lack of performance measures, they said.

One of the biggest concerns of the interviewees was that SNFists contribute to discontinuity of care by replacing residents’ primary care physicians, creating care fragmentation and potentially isolating the SNFist.

In addition, although dedicated care to individual residents is a hallmark of the profession, this is hampered when physicians’ time is spread across multiple facilities, they said. What’s more, important elements of nursing home care are unbillable or under-reimbursed, disincentivizing other physicians from joining the specialty, they added.


The interviewees also offered solutions. The SNFist role should be defined based on competencies, not volume services, the doctors said. Consensus is also needed to create more concrete performance measures in addition to the generally accepted measure of resident-family satisfaction. Efforts are also needed to improve care coordination and to connect SNFists to other specialists in their communities, they added.

The study suggests a strong consensus in favor of increasing the use of SNFists in nursing home care in addition to other physicians with expertise in this area, the study’s authors said. They also encouraged policy makers to step up to support the role.

“[P]olicymakers may consider reimbursing for services currently not covered by Medicare that are frequently performed by SNFists and increase the level of payments for services that are reimbursed to incentivize more physicians to specialize in NH care,” they concluded.

Full findings were published in JAMDA.

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