Renee Kinder

I received a pointed question last week, submitted during the McKnight’s Fall Online Expo and am glad to be able to share my thoughts on it here.

The question: “I’ve been wondering — what about facilities who choose to take advantage of PDPM’s flexibility and reduce traditional therapy while adding group/social exercise classes, and then have therapists guiding the curriculum there? … So it’d be accomplishing the same goals, but with fewer therapy minutes, and not needing the same practitioner:patient ratio?”

My mind was initially spinning with the multitude of variables impacting my response, including: regulatory foundation around the Medicare Part A benefit, the meaning and definition of skilled therapy services, and the concept around outcomes or “accomplishment” noted above.

When we see these types of questions, I also consider: Are they considering how “advantage” is impacting the ones we are trusted to care for daily? For this reason, I want you — even though this article is heavy on regulatory language — to consider a real person,  one of your current patients. Remember that in the end, all of our decisions impact the lives of individuals who enter our care only after some form of change occurs in their clinical/medical status.  

They are trusting us to consider this first. 

Let’s dissect the question and address all critical areas.

What about facilities who choose to take advantage of PDPM’s flexibility and reduce traditional therapy?

For starters, we need not forget the fact that the Patient-Driven Payment Model does not change the criteria for allowing access to the Medicare Part A benefit. Therefore, the standards for determining needs under RUGs IV are the same as the standards for needs under PDPM.

Key consideration also should be given to the definition of daily skill, which does not change. Limiting therapy volume tied to daily skill could cause a SNF to not meet the definition of skill, particularly in cases where the primary skilled needs are therapy- , versus nursing-based in nature. 

Care in a Skilled Nursing Facility (SNF) is covered if all the following four factors are met:

  • The patient requires skilled nursing services or skilled rehabilitation services, i.e., services that must be performed by or under the supervision of professional or technical personnel (see §§30.2 – 30.4); are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services;
  • The patient requires these skilled services on a daily basis (see §30.6); and
  • As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (See §30.7.)
  • The services delivered are reasonable and necessary for the treatment of a patient’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity.

Implementation of group/social exercise classes guided by therapy

For this element, I want us to all understand the difference between skilled care provided by a therapist and what can be achieved via group/social exercise groups guided by therapy.

The skills of a therapist, similar to the skills of a nurse, allow for a unique perspective when care is provided. 

During skilled care, the provider is constantly using their knowledge base and understanding of evidenced-based practice to adjust, alter, modify and improve function (or maintain/prevent decline for skilled maintenance) for the person/patient they are serving. This differs greatly from what can be achieved during a class that is carried out by a non-skilled professional.

Understand: There is a time and a place for each of these levels of care, therapists play a keen role in education, inclusive of return demonstration, to increase knowledge of all caregivers. In cases where a facility is looking for a greater level of collaboration with activities and/or restorative to increase repetition of tasks and promote carryover … KUDOS! 

The key word here is repetition. A guided curriculum can include only repetition to maintain an ability. Skilled care from a therapist is not repetitious is nature. Therapist-based skilled care is aimed at continuous analytics to increase function, or in cases of maintenance, to maintain or prevent decline.

Curriculum guided by a therapist, however not lead by a therapist, does allow the opportunity to add individualization and a prescriptive level of care that is achieved when the care is being delivered by skilled hands. 

Accomplishment of same goals with fewer therapy minutes

To say that this is not within the realm of possibility would be inappropriate.

In considering this element we need to recognize that each patient we serve has individualized needs inclusive of their primary diagnosis, in addition to their complexities associated with comorbidities, prior medical history, caregiver/family support, and desired discharge location.

No two individuals we serve are ever the “same.”

With the increased focus on clinical presentation under PDPM as a determinant for case mix groups, therapists have the opportunity to continue to refine their understanding of evidence-based practice. 

Additionally, there should be continued refinement of how we collaborate across care teams, including nursing. As with any aims that improved integration across care teams, there is the possibility to achieve similar outcomes, independent from volume of care. 

Furthermore, continued analysis related to outcomes should become part of our care team strategy. Areas to consider include: functional gains associated with Section GG Self Care and Mobility item sets, ability to return individuals to the community or to a lesser level of desired care, our ability to increase healthcare literacy, and the ability for individuals to remain in their desired discharge location without returning to an acute-care hospital for the same condition(s).

In closing, will PDPM create an advantage?

Of course it will, hopefully in the best of ways, thereby allowing us to take advantage of the opportunity to refine care, take advantage of working alongside care teams with increased focus on clinical competency and partnership, and in the end leave the advantage to those we serve — our patients. 

Renee Kinder, MS, CCC-SLP, RAC-CT, is Vice President of Clinical Services for Encore Rehabilitation and 2019 APEX Award of Excellence winner in Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty, and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).