Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole. And today, our discussion focuses on insights and strategies building a successful physical medicine and rehabilitation inpatient consult practice. Joining me is Dr. Anthony Phan he is a physical medicine and rehabilitation specialist at Northwestern Medicine’s Marianjoy Rehabilitation Hospital. Dr. Phan, thank you so much for joining us today your role is a bit unique. Walk us through what you do and how that involves working at another hospital in the Northwestern Medicine system

Dr. Anthony Phan: Yeah, sure thing. So, I work as an inpatient rehab consultant. One of my primary roles is to help determine what sort of rehab settings patient would do best after their acute hospital stay. So, whether that's in an acute rehab hospital such as Marianjoy, skilled nursing facility, long-term acute care and in some cases, if patients do well enough, home instead of to a separate rehab setting.

Melanie Cole, MS: That certainly is the goal, and I'd like you to tell us about your experience being the first PM&R physician from Marianjoy Rehabilitation Hospital to work on site Monday through Friday at Northwestern Medicine Palos Hospital, one of the health systems' acute care hospitals. What's that like?

Dr. Anthony Phan: It's been great, my time being here so far. I'm really fortunate because there is a lot of creative freedom. Historically, Palos hasn't had a consistent PM&R presence. There have been groups that have come and go, but nothing long term. So in that sense, there really was no expectations going into it, which gave me a lot of freedom in the sense of creating a service that I had envisioned that would best serve the patient population here in this community. There is a lot of trust and faith both from referring colleagues, patients, all the families that I see to help them make the best informed decision.

Melanie Cole, MS: Dr. Phan, what was it like taking the lead on launching a new outpatient clinic at Palos? What gap or need did you see that led you to start this outpatient clinic? And what have you seen? What kind of difference has it made so far?

Dr. Anthony Phan: I share an office space with Orthopedics, Neurology, Primary Care, Rheumatology. I also work very closely and frequently with Neurosurgery. And so, coming in with a dedicated clinic space for PM&R has been huge in terms of providing a different perspective in terms of diagnosis and treatments of various conditions that may not necessarily have been addressed during those specialty visits or primary care visits.

Another focus or area that I've really been trying to address is making sure that our patients get adequate follow-up after their rehab stays. For example, I had a recent patient that underwent an internal iliac artery aneurysm repair. Unfortunately, a couple days later, he had suffered a femoral neck fracture. And after undergoing a hip replacement, had a post-op course that was complicated by what we suspect as a sciatic neuropathy. That being said, he's currently in acute inpatient rehab. However, this is a patient that I thought would be easily lost to follow-up in regards to his sciatic neuropathy. So, being able to schedule him for an EMG after he finishes rehab, being able to see him in the clinic setting after that study has been done, I think really helps our patients continue to recover long after they leave inpatient rehab.

Melanie Cole, MS: This is so interesting. What you're doing is really exciting. And when we think of your initial goals, what were they as far as raising awareness of the services that you're offering to specialists at Palos Hospital and their patients?

Dr. Anthony Phan: When I first started, the goal was to really expand the window of patients that we classically think of being appropriate for intense therapies. In the rehab setting, here at Palos, there is a prominent geriatric population. And often, these previously highly functional, but elderly patients can be overlooked based on age alone. So, making sure that we give these patients a chance to rehab at a level where their chances of return to the community are the highest.

I think another goal that I had was raising awareness for the staff here. Like I had mentioned before, there hasn't been a consistent PM&R presence. And so, working closely with the case management team, with the hospitalist staff, with physical therapists to ensure that this resource is something that is open to all patients who are appropriate. I think it's especially difficult when Palos hospital is a standalone hospital with no connected rehab unit, compared to other hospitals where they may have a connected rehab unit, it can be challenging sometimes to see the effectiveness of what inpatient rehab can do for our patients. And so for me, you know, the goal was to be a bridge between Palos and a rehab hospital like Marianjoy, where patients after a surgery can recover post-op in an acute rehab setting.

I think surgeons really want to see their patients do well long after their procedures. And so, having that as an option and seeing the improvement of quality of life that patients are achieving after they leave Marianjoy is huge.

Melanie Cole, MS: It certainly is. So, walk us through, Dr. Phan, the initial steps you took to establish your inpatient consult practice and outpatient clinic, how you went about integrating into the culture at Palos Hospital. Tell us a little bit about some of those steps you took in building your practice and your contacts. I mean, it had to be a lot of work.

Dr. Anthony Phan: Certainly, when I first started, Palos had just recently been acquired by Northwestern. And so, there were a lot of changes. And when I had come in, I really didn't know anybody. I. And so, my initial goal was to try to meet as much hospitalists and different specialists at Palos Hospital as I could. That certainly was a challenge.

And I remember my first couple days starting where I had sat down with myself and came up with one big goal, which was to meet one new person a day. And as each day went by, I slowly met more and more of the medical staff here. I got to know them better, which really did help build the relationship. And additionally, I don't have a dedicated office space. And so, I took it to myself to be in an area with a standing desk, and this area that had a standing desk happened to be an area of high foot traffic. And so, that really helped in terms of being able to meet other hospitalists, other specialists.

And another point is I feel that it's very hard to talk about the consult service without talking about my EMG practice as well as my clinic space, which really did help grow my consult service and vice versa. Having a dedicated space for EMGs in clinic has really helped with the continuity of care. I feel like it's helped with efficiency of care. So, those patients who not necessarily ended up in acute rehab could still have access to resources and care that would help diagnose and/or treat medical issues affecting their function. And for those that do end up going to acute inpatient rehab, having a space where patients can continue to rehab and recover long after they're discharged from acute inpatient rehab.

Melanie Cole, MS: What were some of the biggest challenges, Dr. Phan, you faced in the beginning? How did you overcome those?

Dr. Anthony Phan: it's really difficult to talk about inpatient rehab without having the conversation of insurance coming up. No one really teaches you how to do a peer-to-peer, and everyone has their own way and approach of doing these peer-to-peers with insurances. And so, that has been some of the biggest challenges, especially with a lot of these patients having Medicare Advantage plans. There are oftentimes where a peer-to-peer is offered. And I think knowing that whether or not they go to inpatient rehab is determined by the outcome of this conversation can sometimes be a high stakes conversation, but that also gives me a lot of motivation to get to know my patients better, so that I can best advocate for them during these conversations.

Another big challenge has been the timeline and being patient with recommendations, especially in the face of metrics such as length of stay, when there is a pressure by the primary team, by the social workers and case managers to help figure out a disposition as soon as possible. And I feel fortunate that a lot of the teams that I work with here are very patient and willing to work with me to allow me to evaluate patient progress when it's difficult when I first meet them, to come up with the determination of where they would be best.

Melanie Cole, MS: Dr. Phan, you had a mentor, yes? Tell us a little bit about that and how that's contributed to the success of what you're doing.

Dr. Anthony Phan: So before I started at Palos hospital, there was a physician, Dr. Nelson McLemore, who really got the service started and running from the ground. He was already working full time at Marianjoy and before I started would actually add the consult service at Palos to his usual work week. He's someone that I highly admire. He's worked both on the insurance and the clinical end of healthcare. So, he's someone that I really trust when it comes to how to best assess and handle complex cases, both medically and from a social standpoint as well. And overall, just an overall great guy who I really look up to and has been a lifeline that I can call whenever I'm in need.

Melanie Cole, MS: Dr. Phan, before we get ready to wrap up, I'd like you to share any success stories or patient outcomes that highlight-- you told us one already. Tell us ones that highlight the impact of that consistent PM&R presence at Palos Hospital. And because you're telling us success stories, If another physician PM&R physician, were preparing to launch an inpatient consult practice or outpatient clinic in an acute care hospital, what's your best key advice?

Dr. Anthony Phan: So, I had a patient who was in his 30s who had come to us from a skilled nursing facility when evaluating his prior level of function, he hadn't walked for over a year. He was actually in an outpatient neurology visit when he was then advised to be a direct admission from Neurology after an EMG study returned concerning for CIDP. When I first saw him, he was very debilitated, was very dependent and required a lot of assistance and. I think for a lot of the cases that we see, a lot of our assessments is based on prior level of function. And for someone who hasn't walked for over a year, it's easy to have doubts on what sort of progress a patient like this can make.

However, as he was at Palos through the week and weeks that he was at Palos, I did see the progress and the potential that he could make and eventually we were able to get him to Marianjoy. And he got to a point where he made enough functional progress to safely discharge home at a level where he was ambulating. You know, I think that he's a great example of a patient who may not have a convincing prior level of function, however, who has demonstrated potential. I do think it's super important to go into each consult with a fresh set of eyes. Oftentimes there's patients that initially come from a skilled nursing facility who may be best returning to a skilled nursing facility. However, there are cases where a patient may have a change in medical conditions and treatments and may actually demonstrate improved potential, and those are the patients that we really need to reach out to so they don't slip through the cracks.

Melanie Cole, MS: Now, Dr. Phan, just really sum it up for us. Give us your key takeaways for other providers and what you would like them to know about the program that you started at Palos Hospital in conjunction with Northwestern Medicine's Marianjoy Rehabilitation Hospital.

Dr. Anthony Phan: One of the important things is to follow your patient's progress, especially after they go to acute rehab and even after when they leave and graduate to see how they're doing afterwards. I think these patients are great case studies for us and great learning experiences to see which patients do the best, so that way we can better serve future patients that we encounter.

I also think it's important for our referring physicians and providers to know how well their patients can do in an acute rehab setting, whether it's a surgical or non-surgical patient. I would say another important thing is to have consults put in earlier rather than later. It's a great opportunity to get to know a patient as sometimes for patients, it's really hard to know a patient's potential when you first meet them at times. Being in an acute hospital setting is a very messy time. There's a lot of ongoing medical issues, workup that's being done. There are psychosocial factors that can be unfolded. And all of these taken together may become more apparent and may help you make a determination of where they'll do best afterward.

And lastly, I would say having a grip on emotional intelligence. By that I mean getting to know your therapist well, so that's your physical therapist, occupational therapist, speech therapist, because they do spend a lot of time with these patients and they know them best. And knowing each therapist well really does help because for what we see on paper, a mod assist for one therapist may look very different from a mod assist from a different therapist. And having an understanding that each therapist has a different threshold for what they determine in terms of their level of assistance that they need, I do think there's a lot of medical necessity that can be uncovered from these therapy assessments when you speak with them, things such as focal pain, which may be limiting some of their potential. There may be other undiagnosed conditions such as focal weakness that could be coming from a myelopathy that wasn't initially addressed. I remember I had a patient who had a gout flare that really made it difficult for him to tolerate standing and transfers. And after treating that, did a lot better and eventually became appropriate for inpatient rehab. There are medications that patients are on before, such as midodrine. And so, knowing that these medications could have been accidentally stopped during their acute care course, knowing that if we can resume it, that may help with orthostatics and, essentially, paint a better picture in terms of what they can achieve once they get to acute rehab.

Melanie Cole, MS: So many little details. That was so interesting, your last answer, Dr. Phan. That makes so much sense when you speak about things that might have been dropped along the way as they entered into rehab. That is interesting. And thank you so much for sharing this expertise for other providers. You've given us so much great information.

And to refer your patient or for more information, you can head over to our website at breakthroughsforphysicians.nm.org/rehabilitation to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for physicians. I'm Melanie Cole.