Thursday, January 16, 2014

Management Tips (and Commentary): Skilled Nursing Rehab

Welcome to another episode of Management Tips, last post featured Acute PT. This time, we're going to talk physical therapy practice in the skilled nursing facility (SNF). I do want to first disclaim that this post is less organized as compared to my Acute PT post - it is more of a conglomeration of thoughts much as in the style of which Miyamoto Musashi wrote in his Book of 5 Rings (my next Martial Arts Musings post!) - if anything, I think for the many PT's working in geriatrics, this post will be much validation to know that you're not alone - AND - that there are, indeed, solutions!

Despite the financial weight and enormous revenue that "therapy" (I'll be complaining about this term later) brings to a skilled nursing facility, most SNF's use contract companies or vendors (internal or external) to supply rehab therapists in the rendering of service and billing thereof. The irony is that much of the time, "therapies" (again, later...) can easily account for half the revenue in your average SNF. Moreover, most residents that find themselves "skilled" for the stay tend to qualify for such metrics because of the "therapy" (ugh...) involved. So what's the beef? Why isn't "THERAPY" running the show?

Well, first and foremost, this is due in part to the fact that Medicare (amongst other insurances) views skilled nursing to be the primary service rendered at the (appropriately titled) SNF. Skill nursing is an extension of medical care and supervision by where a physician can remotely manage the now stabilized conditions of its residents post discharge from the acute hospital setting. "Therapy" (okay, I'll complain next time. PROMISE!) is seen as an adjunct; a component of the care provided at the SNF - despite the fact that in all realism, it in fact drives the care and discharge disposition for most residents.

The other challenge in the SNF setting is this: in the continuum of healthcare, the SNF is essentially the ultimately middle man of the entire system. The costs to run such facilities are great, fortunately, the revenue can be equally great. The profit margin is the challenge. And thus, many SNF's are operated heavily with accounting principles in mind.

So let's start here. First, most reimbursement models in the skilled nursing are based on RUG's (Resource Utilization Groups) which is nothing more than frequency of treatment and total minutes of treatment in any given time adjusted week. While strategic setting of RUG levels, COT's, and transition to RNA programs are very essential elements in managing rehab services in the SNF setting, all that content is more of an MDS talk... I'll just leave it at that. What perhaps is more important to remember is that maintaining high utilization is a pressure point that the healthcare administration (not to mention business office) will always be asking about. As such, some SNF programs utilize split treatments throughout the day to fulfill RUG levels or use modalities such a diathermy or NMES. Sadly, what you notice is a focus on the financial qualifiers and less on the clinical aspects of the care. The challenge? BALANCE.

The other challenge of managing rehab in the SNF setting is patient and workforce flow. Essentially, the SNF is a dumping ground for hospitals during key dates and seasons in the calendar year. Additionally, it serves as a type of restaurant business model by where you never quite know how many customers are going to walk through the door... and, you really don't know how many will walk out at any given time. In essence, it can quickly turn into a supply chain crazy place. You get a sense of what is coming down the pipe - sometimes. Most of the time, you just don't know and just hope that this year is much like last year. That is, of course, if you don't have well developed relationships with your referral sources. Ahhh, yes. It *is* who you know.

Strong SNF programs have fruitful relationships with local hospitals, particularly that of the case managers and social workers in said hospitals. More importantly, good SNF's will develop very close relationships with insurance case managers who ultimately approve the payment (and many times referral) of care. NOW we're getting somewhere. Since managing SNF rehab has more to do with managing flow of residents in and resident out than it does anything else, then it behooves all SNF rehab programs to be on excellent terms with case managers (both clinical and utilization review) who heavily influence the referred flow from the acute hospitals.

Once the flow of referrals are under wraps, the resident discharge disposition needs to be carefully regarded; primarily, the considerations of home, home with caregivers (which will only increase in the year of 2014), home with home health, or outpatient follow ups. Before things even get this far, we must remember that ACO's and managed care organizations alike stand to gain financially from decreased costs (aka. decreased lengths of stay and decreased utilization of services) but also stand to lose A LOT due to re-admission and/or sequelae. This is a narrow equilibrium for all tiers of the healthcare supply chain to consider. THIS is when things get into that discussion of what is "medically necessary" and what services are considered to be "skilled."

SO! Let's talk about "skilled therapy." (Yes. It took a LOT of discipline and several re-edits not to have that word before this moment.) Oh yeah... Get ready! The purpose of the SNF (from an economics standpoint) in the flow of healthcare is that such facilities present a less costly, less medically intensive inpatient care as compared to the acute hospital. If patients/residents do not require the intensity, attention, and skill sets present in the hospital, then the logical step down is skilled nursing. Below that would be home health, outpatient, and  finally, wellness/preventive care. So to backtrack just a moment, acute (with physician on site) stepped down to skilled nursing (with physician remotely, medically stable enough to be inpatient, but, not stable enough to be at home)... this line in the sand of inpatient vs. home is what "skilled" is all about. That basic question: can the services be rendered at the skilled nursing facility be replicated by lay people, say a caregiver or family member? If so, then you should be home. Assuming there's a reasonable assessment that being at home isn't detrimental to health/safety and wouldn't lead to readmission to a hospitals or emergency department (within 30 days...). If not, then a patient would find themselves safety (from a physical & medical standpoint) as a resident in a skilled nursing facility.

There's a singular problem: many times, what we find in the skilled nursing setting is that many things are simply NOT skilled. We already saw this happen in the industry back in the 80's and 90's with outpatient services. If you're ears are ringing the way mine are, you heard it correctly: cost, Cost, COST! How to contain it, drive it down, and, how to do so and still develop good revenue and margins without blow back from poor outcomes, beneficiary dissatisfaction, and regulatory penalties?

The cardinal problem is that skilled nursing (as with any area of the healthcare industry) is still a business at the end of the day. There needs to be more dollars coming in than going out. SNF's stand to gain to keep residents as long as possible; the people paying (insurance companies) stand to gain to discharge as soon as possible (assuming readmission is not a likely event). This will always be a tug of war until health systems begin to share costs and outcomes across all practice patterns (HUGE other discussion I should hope to write upon in the future).

But, I do digress, what about the "skilled therapy?" Well first, everyone knows that nearly all residents/patients/family members consider "therapy" to exist as physical therapy. Occupational therapy is apparently also a form of physical therapy. Speech therapy (as usual) is in its own world, as perceived by the consumer. Oh, yes. And all rehab staff are "therapists." THIS IS TERRIBLE! Not only does this completely dilute the value of all disciplines, the degrees they earn, and clinician licensures, this basically tells us that there is nothing "skilled" going on! If consumers can't tell the difference... well, then what's the point? If the idea of skill rehab is to quickly and safely return residents back to their homes (at levels where premature hospitalization is avoided), there are questions that are begging - questions such as: (1) Does it really take a Doctor of Physical Therapy to perform a maximal transfers of two persons for a medically complex patient with a medical diagnosis of pneumonia? (2) Is the supervised/contact guard/minimal assistance level of gait (without need for neuromuscular facilitation) truly a skilled event? Something that a caregiver, family member, or nursing assistant couldn't do? (3) When will SNF's begin to build relationships with insurance carriers to define solid, concrete, objective criteria AND time tables to discharge disposition? Such as the basic: No one goes home without 24/7 care if a resident demonstrates a Tinetti POMA less than 19?

Truly, what would be a better use of "skill" would to high levels of case management and case delegation from a supervising physical therapist to the maximal amounts of assistants. Ideally, state restrictions on the number of supervised assistants and aides need to be severely liberated. Not only would this make costs more manageable, this would make the level of care delivered realistic with the level of skill required at this setting. After all, most of skill nursing rehab isn't exactly the ICU; it isn't exactly a large caseload of dry needling, spinal manipulation, complex wound care, or neuro rehab... is it? I mean, let's be honest here. I'm not belittling SNF rehab, at this moment, I'm a director of a SNF rehab program. What I AM saying is that the utilization at SNF's need to be carefully reviewed and restructured for future sustainability and justification. Enough said (for now).

Speaking of structure. One of the biggest management tips I can list is to build infrastructure. All too often, our poor and overworked director of rehab (DOR) is the centerpoint and corner stone of the entire operation. If the DOR is out, the department loses half of it's operational strength. Sound familiar? Additionally, turn over in SNF's are tremendously frequent. There is usually an anchor team which has stuck around for a while; there is also a regional population of wandering clinicians picking up any hours they can find at any number of facilities. So how can one build infrastructure? Hint: See my paragraph above. With revisitation of skill set and appropriate labor utilization, there is much to be said about the cost containment and performance metrics that corporate will impress upon any program. This, of course, takes much time and legislative development.

Nevertheless, there are still ways. First, identify primary or lead clinicians for all disciplines. Identify a 2nd in command and a 3rd in command from those leads in lieu of the DOR. If there is an outpatient program attached to the SNF, be sure to develop an outpatient coordinator position. A rehab aide/tech/secretary is VERY helpful in any program. Since most DOR's are fixed costs, it stands to reason that the process of scheduling & staffing (which usually takes way too much time for most facilities) can easily be delegated to a non-licensed staff member - much as outpatient clinics operate. Also, this will free up the DOR to see more patients and get increasingly involved in the case management and direction of care throughout the facility. Finally, EVERY staff member needs to be empowered to tackle the many service recovery opportunities that exist in the SNF setting, and, be intimately aware of how payer source and treatment frequency are related to the daily operations.

So we've covered the elements of business relations in SNF Rehab as well as operational infrastructure. There is one more aspect I'd like to discuss in management tips for SNF Rehab; this is the topic of employee engagement. Again, I'm going to ask that we be honest with ourselves. Employee engagement in outpatient settings, acute rehab/inpatient neuro, and largely even in home health is fairly organic. There is enough stimulation with a day to day "I feel like I've actually helped someone" in the mix that engagement isn't a risk factor for those settings. However, SNF Rehab is a high risk setting where clinicians can easily and very quickly burn out without strong levels of staff engagement. Most markets try to make up for this by paying SNF clinicians the highest in comparison to any other setting available; more money to tolerate more nonsense and to keep from complaining. However, we all know, money isn't everything.

My best advice when it comes to employee engagement in the SNF setting is to empower the staff to three, typically easily achievable, facets of practice: (1) take ownership of the business. This extends to things such as the day to day, customer service & recovery, understanding what payment models do what and how that affects their own practice. (2) Take ownership of a specialty. Have one clinician be the seating/positioning specialist while another specializes in neuro and yet another in wound care, etc. (3) If the facility/community is agreeable, organize regular inservices by which the rehab staff teaches the community staff about rehab, ergonomics, and workplace safety - we are teachers of health, after all.

Some Closing Thoughts
SNF Rehab is under high levels of scrutiny by all sides. Clinicians are questioning the ethical stance of the practice patterns that have been laid and grandfathered in from the past. Payer sources are questioning the utilization. Customers are skeptical about the quality of care and the lengths of stay. Additionally, since healthcare is going into a cost containment model to achieve best outcomes through the lowest cost, SNF utilization will only increase as a measure of early discharge from the acute hospital. However, this same model will only cause shorter lengths of stay in the SNF. While residents can easily readmit themselves to the SNF without going back to the emergency department, this doesn't change the fact that insurance carriers will be pressuring facilities for early discharge - AND - eventually ACO's/Medicare will be more readily auditing high RUG levels and longer than average lengths of stay. Two words: PEPPER reports. Oh yes, one more thing, this only will unfold as such if SNF's actually demonstrated the value of their "skill" - if the outcomes are no different, things will simply (as they are beginning to) heavily shift into home health and just bypass that middle man who may cost just a little too much.

The other aspects of SNF Rehab management include employee engagement, developing strong relations with hospital & insurance case managers to assess supply chain flow, and building sound operational infrastructure amongst the staff. Personally, I find that the building of infrastructure is the most difficult piece to solve. Most rehab companies in the SNF setting impose some incredibly high productivity standards to their staff. Most of the staff just keep their heads down and run between treatments while they document at point of service to manage the standards so that they aren't written up. This is, again, a terrible way of managing staff since all they do is live in fear they'll be written up for something they can't actually control. Instead, if managing costs and operations is the goal, it is best to start backwards. As I mentioned in the middle of this post, really reevaluating what is "skilled" is a good place to start. Using this lever to move the needle in the realm of licensures in liberating who/how licensed clinicians can supervised under them will really be bottleneck for realistic solutions.

In any case, for the time being, SNF Rehab management is also waiting for healthcare changes in the year of 2014 to fully reveal itself. It's a rather unsure time in that no one quite knows how the market will behave once the legislative climate settles down. In that regard, managers and company executives need to bulk up for any possible looming storms. Acting like the situation will take care of itself is simply asking for trouble. The proof is in the many SNF's that are already closing PRIOR to the full force of the 2014 changes.

Since I like to close with positive thoughts, I will highlight that the best business move for SNF's is to developing very strong relationships with the case managers who determine hospital discharges as well as those in utilization review who determine payment. Case managers that hear that your facility's rehab program is the best; best staff, best results, and most economic will favor you against competitors. This reputation will also help engage the staff at large and serve to bring more positivity to the equation. And, in this current economic climate, programs can use all the positivity it can hang on to. It's up to our managers to find it, cultivate it, and retain the momentum. For, in the midst of uncertaining, a strong team cohesivement and positive dynamic is the best weapon you have to encourage a culture of stability.


  1. Hello Dr. Fung,

    I’ve really enjoyed reading your blog over the past year. I stumbled upon it when got more focused on the problems that seniors have with mobility and injuries, and I was immediately hooked by your focus on life. I really enjoyed your post about skilled nursing rehab. When dealing with senior's like my grandparents and their friends, it was no surprise to see the same challenges facing them every day. One of the biggest problems I notice with my grandparents is their mobility starting to slow down.

    I currently am working with a team that has a project set to launch in the next month on Kickstarter called the step2rest ( ). The creator is a nurse who is focused on helping keep the senior population safe in their home, I thought I might share it with you.

    Would you be interested in doing a interview/guest entry/review on him and the project for your blog? My hope is that it would add value to your audience, especially since it’s in line with helping people reduce their risk of falls and remain independent as long as possible.

    If you'd prefer to review the final copy of the product, I would be happy to send you additional information or perform a demo with you privately. Thanks for your time, and I look forward to future entries about the problems seniors face in their home.

    We also would be willing/open to making a blog entry that you could post as well. Look forward to hearing your feedback. You can contact my friend beneath

    Vince Baiera R.N., BSN

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  3. While this article is a few years old by now, the theme still holds true. I continue to wonder how and when CMS and other related fiscal intermediaries will catch on to the burn out they have created in the SNF setting for clinicians.
    It is of equal importance for SNF companies to recognize how demanding productivity and utilization can be. If only they could recognize that they are sacrificing QUALITY and exceptional care when they place unreasonable demands on patients and clinicians alike.

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