Kristy Brown

Regulations are a fact of life in the healthcare community — but can too many regulations prevent professionals from delivering on the promise of the Triple Aim? The goals of the Triple Aim are to provide better experiences of care for individuals, improve population health and reduce healthcare costs. That is what my agency expects of therapists and what we expect of management. It is a big part of our strategic plan as well as our business plan.

Then, along comes a state survey of our rehabilitation agency. Agency status allows us to go into sites such as adult day centers and assisted living communities. Once there, we can provide care through Medicare Part B and other payor sources because these care communities are not Medicare certified.

My company has had this agency status since 2002 and made it through all surveys deficiency free. With increased focus on the triple aim, we are attempting to meet the objectives set before us. This recent survey really opened my eyes to the need for regulations to be changed.  

One site we serve is in an adult day center, in a small building that offers wonderful day and nursing services for participants with memory issues. We offer cognitive testing, gait training, wheelchair modifications, and more. Centrex offers these services through training for staff and care givers, as the majority of people who need memory care are unable to master new information. Therapy staff serves as part of the interdisciplinary team who are present while the adult day center is open.

Due to the small number of participants and high staff-to-participant ratio, the center’s overall staff is very involved and completely capable of dealing with any people who join us there. Yet, the surveyor told us we were out of compliance for safety reasons, as we are supposed to have two employees from the same company in the building during all patient treatments. At that point, I had to politely question her about how patients could be unsafe when the entire interdisciplinary team is present. I realize that regulations do stipulate two employees must be in the building, but in the past regulators have let this pass, due to all the supportive staff we have around us constantly.

We do not see a lot of patients at the adult day center and do not encounter multiple therapy needs simultaneously. When thinking about this regulation, I can understand that when an outpatient clinic is not integrated into another setting (such as we are in each of our agency sites), clinics must abide by the two-therapist rule. However, I do not feel this should apply to us.

I say this because we do not see a great number of patients in this particular setting and we have been breaking even (if not losing money) with only one therapist on site. Adding another therapist or aide will add mileage costs and payment for time he or she spends in the building while the other therapist provides treatment. That is just too costly for us.

Other regulations also do not support the triple aim. The cost paid by the state to have the survey completed must be astronomical. The surveyor was in our buildings from Monday through Wednesday and continued communicating Thursday throughout the day, while documenting survey results. When working with an agency that only sees on average 20 patients per month in safe environments with qualified personnel, the surveyor’s actions seem excessive. This is also only about one percent of our business but it still provides a very valuable service to the community.

I am a huge proponent of the auditing and chart review process. I have spoken at several state conventions with a renowned attorney on the importance of the audit process. When our quarterly audits have such positive outcomes and you have only a few employees that provide the treatment, it seems wasteful to keep such an intense focus on the review process. Centrex Rehab therapists, who are all registered therapists and not assistants in this setting, are scoring 95% to 100% routinely on the audits. Again, while I realize that this is a regulation, I had to ask the surveyor if this could be altered, based on the excellent quality of care that is documented in our paperwork.

As an administrator of this agency, I have always been proud that we are able to provide services in a variety of settings and families or caregivers do not have to go to outside appointments. But, again as the administrator, I am faced with the costs of delivering therapy services. If only the regulations would better reflect the triple aim, which we remain focused on, we could continue providing this great care, which I truly believe keeps participants from going into a nursing home.

I am sure that whatever healthcare environment you are in, you are likely to experience the same types of pressure. We all need to remain active in letting the government know what we think in a positive and professional manner. I also want to add, we should not be afraid of educating surveyors about our work. They are not policy changers, but they need to start seeing that the triple aim is here to stay and that it’s where the future of healthcare lies.

Centrex Rehab CEO and President Kristy Brown is a speech language pathologist, and previously was the executive director of therapy services at Augustana Therapy Services from 1999-2012.