“I’m too sick for therapy today.” 

“Come back later.” 

“Leave me alone.” 

If you’ve worked in long-term care (or hospitals or LTACHs or acute rehab hospitals), you’ve heard that before. The older client who misses his wife, misses his home, misses his kitchen, and has just about had it with these people who won’t let him sleep, won’t let him get up by himself, and won’t let him go home. 

Recently, a friend who works in a skilled nursing facility has been experiencing this firsthand from her own father. 

Her father is a brilliant and accomplished man with a bunch of degrees and a big family. He has spent 70+ years making his own decisions, operating independently, and answering to few. After several falls at home and a subsequent hospitalization, he’s a resident of a SNF. And he’s not cooperating. 

His wife is living with dementia and is in the SNF’s attached assisted living facility, where she contracted pneumonia and is not able to come over to see him. He misses her, and that isn’t helping. 

The rehab staff at the SNF is done approaching him for therapy. They’re giving the time-worn and time-refuted nonsensical and mythical excuse that “Medicare says if he refuses three times, we have to cut him.” This myth has been around longer than I have, and it is not to be found in any documentation related to Medicare coverage and is nowhere to be found in Chapter 8 of the Medicare Manual.

The other excuse they’re giving is that when he does participate, it’s too sporadic for the goals to be reached and is “merely maintaining his function.” According to Chapter 8 of the Medicare Manual 30.2.2.1:

“…when skilled services are necessary to maintain the patient’s current condition, the documentation would need to substantiate that the services of skilled personnel are, in fact, required to achieve this goal. … In situations where the maintenance program is performed to maintain the patient’s current condition, such documentation would serve to demonstrate the program’s effectiveness in achieving this goal. When the maintenance program is intended to slow further deterioration of the patient’s condition, the efficacy of the services could be established by documenting that the natural progression of the patient’s medical or functional decline has been interrupted.” 

This patient has been cut from Medicare on the basis of pernicious misinformation, and he has been told he doesn’t qualify for Part B therapy. What? If he were going home, he would qualify for Part B because Part B is outpatient therapy. 

Whether he’s a long-term resident of the facility or is living in his home, Medicare considers Part B to be outpatient. If he refused or otherwise missed some outpatient sessions, as one might who lived at home, the provider is at no risk to Medicare. At first glance, this appears to be petty and a little outrageous. 

It’s extremely outrageous that all of this is a result of the widely accepted and wildly escalated need for productivity for therapists. This patient abandonment was clearly done because the therapists are 

expected to achieve 85% or better for billing vs. time on the clock. This client requires too much time devoted to coaxing him to come to therapy and adversely affects expectations for the therapists. 

We know that Jimmo vs Sebelius in 2013 confirmed that “progress” is not required for patients to be skilled and that the mythological “plateau” is not and has never been a recognized part of our scope. 

Yet here we are, and our clients are suffering and being underdelivered because of the unrealistic expectations that therapists are held to and using patients’ sadness as an excuse. 

I know rehab companies and SNFs are trying to keep their heads above water in an ever-more-stringent healthcare environment, but it’s frequently at the expense of those we serve. My motto has always been, “Do the right thing for our patients, and the money will follow.” We need to remember why we’re here and keep fighting for what’s right.

Jean Wendland Porter, PT, CCI, WCC, CKTP, CDP, TWD, is the regional director of therapy operations at Diversified Health Partners in Ohio.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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