How to Fix Poor SNF Care Outcomes Through Physician-Led Collaboration

Is your skilled nursing facility (SNF) struggling with poor care outcomes? You’re not alone. Preventable hospital readmissions, medication errors, low patient satisfaction, and regulatory issues are common in SNFs and long-term care facilities. For example, according to KFF, the share of nursing homes reporting severe deficiencies increased from 17% in 2015 to 28% in 2024.

Various issues contribute to poor care outcomes, including fragmented care and inadequate staffing. Strong physician leadership is the key to overcoming these problems. Leadership-minded physicians can help your SNF create a collaborative, supportive work environment that prioritizes high-quality patient care.

At First Docs, our physicians bring the clinical expertise and strong leadership needed to solve complex challenges. Our physicians are dedicated to helping SNFs develop a collaborative care culture by actively engaging with the centers, patients, and residents they serve, and prioritizing proactive interventions and effective care coordination.

The High Cost of Poor Care in SNFs

Poor care can have significant consequences, ranging from patient harm to high turnover rates. Here are just some of the impacts:

Patient Impact

Poor care often results from inattention, miscommunication, or a lack of clear standards. It directly impacts patients and residents, increasing the risk of falls, infections, and other forms of preventable harm. When patients and residents experience harm due to substandard care, feel unattended to, or witness repeat errors, their physical and emotional well-being suffers. They lose trust in the people who are supposed to care for them, adding to their distress.

Facility Impact

Poor care impacts your center from every angle, leading to the following:

• Reputational harm: Poorly managed care contributes directly to hospital readmissions. The Centers for Medicare and Medicaid Services (CMS) considers readmission rates when assigning star ratings to SNFs. A lower rating impacts a SNF’s ability to attract new patients and residents.
• Decreased reimbursement: The Skilled Nursing Facility Value-Based Purchasing Program can decrease reimbursement amounts if SNFs do not meet hospital readmission targets. Also, poor care often goes hand in hand with incomplete documentation. This means SNFs might not classify residents correctly when using the Patient Driven Payment Model (PDPM), resulting in lower reimbursements.
• Staff burnout: Poor care means more work for everyone. Staff must tend to residents with preventable injuries or infections. They must also spend more time completing incident reports. When dedicated staff know patients and residents aren’t getting the care they deserve, their morale plummets, and they leave to work elsewhere.

The Link Between Fragmented Teams and Poor Care Outcomes

When teams are fragmented and communication is lacking between physicians, nursing staff, therapists, and external providers, no one has a complete picture of a patient’s or resident’s health. This can lead to treatment delays, medication errors, and unnecessary tests.

Fragmentation also makes it difficult to establish complete documentation. When silos exist between teams, you can’t capture the information needed for proper PDPM reimbursement or comply with numerous record-keeping regulations.

How Physician-Led Collaboration Fixes Poor Outcomes in Skilled Nursing Facilities

Managing a SNF is not easy. You’re juggling staffing shortages and complex compliance requirements, all while supporting patients, residents, and employees the best you can.

This is where consistent, reliable access to physician leadership can make the difference for any skilled nursing facility interested in care quality improvement. A physician with strong leadership skills can help your clinical teams overcome common challenges by driving collaboration and clear communication as well as offering expert guidance. Physician-led collaboration in skilled nursing facilities has unique benefits because it combines clinical expertise with a deep understanding of how the SNF system works.

Leaders like medical directors can assist SNFs with the following:

• Setting and reinforcing high clinical standards.
• Promoting daily or weekly interdisciplinary team meetings.
• Facilitating better handoffs and communication protocols.
• Ensuring timely interventions to prevent adverse events in patients and residents.
• Supporting Quality Assurance and Performance Improvement (QAPI) programs and regulatory compliance.
• Fostering shared accountability across all care team members.
• Helping SNFs improve key metrics like hospital readmissions, CMS survey scores, medication errors, and PDPM reimbursement rates.

The First Docs Approach to Physician-Led Medical Management in Skilled Nursing Facilities

First Docs physicians are trained in internal medicine and serve as both attending physicians and medical directors. Unlike traditional models, where medical directors are overworked and disengaged, our physicians are actively involved in your center’s day-to-day operations. In other words, they aren’t just there for compliance purposes — they are genuinely committed to transforming your SNF into a more collaborative, patient-centered environment.

Our physicians understand that no two SNFs are alike. They use a tailored approach to build a culture of teamwork, effective communication, and shared decision-making. No matter your center’s challenges, our medical directors can help you get on the right track. Here’s how:

• Develop a standardized process for conducting rounds and oversee its implementation.
• Lead QAPI meetings, facilitating discussions around communication, coordination, and collaboration as needed.
• Ensure staff feel supported by providing clinical guidance and mentorship.
• Standardize evidence-based protocols to set clear expectations and facilitate teamwork.
• Build partnerships between your SNF, hospitals, and outpatient providers, enhancing care coordination.

Ready to Improve Care Outcomes at Your SNF?

When strong physician leadership is absent, prioritizing collaboration and care outcomes becomes unrealistic. Staff might not have the time or leadership skills to initiate collaboration themselves. They need the guidance and support of dedicated leaders. That’s where First Docs comes in.

We bring the leadership skills, clinical expertise, and proactive engagement needed to transform your center from one that focuses on quantity to one that prioritizes quality. Contact us today to see how our medical directors can drive better outcomes at your SNF.