There are many myths surrounding rehab services in skilled nursing facilities. I have, of course, encountered them myself and have learned they often come from a lack of understanding of skilled care and a need to increase knowledge of Medicare regulations.
While the following situations may sound absurd, I’ll bet we have all encountered them:
• “You need to wait until Friday to assess Mr. Jones so nursing can document for three days.”
• “Ms. Able can only complete a stand/pivot transfer in the rehab gym.”
• “Mr. Smith has advanced dementia. Therefore, he cannot participate in therapy.”
Did I say absurd? OK, I meant ridiculous. It’s time to set the record straight.
My Top Therapy SNF Myths. Busted!
“You need to wait until Friday to assess Mr. Jones so nursing can document for three days.”
Myth #1: Three days of Nursing documentation is needed prior to therapists assessing a patient.
Fact: When a functional change in status is noted, therapists can screen a patient in order to determine the need for further assessment. The therapist assessment determines the need for skilled therapy services. Waiting for three days in order to allow nursing to document the functional change is not only unnecessary, it can place a patient at increased risks, depending on the areas of concern.
“Mr. Jones needs a new chair cushion due to leaning. Let’s have therapy screen to recommend a new one.”
Myth #2: Therapists can screen a patient and make recommendations.
Fact: No recommendations can be made from a screen alone. Screens are “hands-off” and tell a therapist simply whether or not further evaluation is warranted.
“Ms. Adams needs a maintenance plan to train swallow techniques for her new diet. Speech therapy will have two to four visits to address.”
Myth #3: Maintenance-based care, per the Medicare Benefit Policy Manual, can last only two to four visits.
Fact: Maintenance-based programs are covered therapy services, services aimed at maintenance of functional status or to prevent or slow further deterioration in function.
Coverage for skilled therapy services related to reasonable and necessary maintenance programs are available in order to establish or design maintenance programs and to deliver a maintenance programs.
These services are covered when a patient’s clinical condition demonstrates that the specialized judgment, knowledge and skills of a qualified therapist are necessary for the performance of safe and effective services.
Time limits are not established for frequency or duration of maintenance-based care. The deciding factors are always whether the services are considered reasonable, effective treatments for the patient’s condition and require the skills of a therapist.
“Our new admission only needs ST and not PT or OT. Therefore, we can not skill.”
Myth #4: Speech Therapy alone cannot skill a patient.
Fact: Speech therapy can provide skilled rehab services without other therapy disciplines also providing care.
“Therapy needs to review and sign Section: O of the MDS. However, other sections do not apply.”
Myth #5: Section O of the MDS is key area therapists should know.
Fact: Section O of the MDS contains elements related to documentation of therapy minutes, in addition to providing clarification as it relates to various modes of treatment.
In addition, there are many sections of the MDS that contain critical clinical elements that can be of benefit to therapist as listed in the table below.
“Ms. Brown is receiving physical therapy so she can walk longer distances.”
Myth #6: Physical therapists treat gait (i.e. walking) to increase distance.
Fact: As described in of my prior McKnight’s articles, skilled PT interventions include complex processes associated with gait that include aspects well beyond increasing distance alone. Key areas affect gait pattern, including base of support, swing phase, stance phase, heel strike, toe off, stride length and cadence. PTs also assess and treat gait patterns across a variety of surfaces, including level surfaces, uneven surfaces, stairs, curbs, and the ability to negotiate obstacles in order to promote individuals’ safe return to prior levels of function.
Additionally, individuals who are not immediately appropriate for gait task may be able to participate in pre-gait interventions aimed at improving weight bearing, static standing balance and ability to spontaneously right self.
“Mr. Smith has advanced dementia and, so he may not participate in therapy”
Myth #7: Medical diagnoses and prognosis should be a factor in determining skilled therapy needs.
Fact: Per the Medicare Benefit Policy Manual, “while a beneficiary’s particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiary’s diagnosis or prognosis cannot be the sole factor in deciding that a service is or is not skilled.”
“Ms. Able can complete a stand/pivot transfer only in the rehab gym. However, she requires moderate assist times two to transfer in her room.
Myth #8: What happens in the therapy gym stays in the therapy gym.
Fact: In order to promote functional carryover of techniques learned in skilled therapy sessions, it is crucial that techniques are trained in settings outside of the therapy gym. Therefore, active engagement between all caregivers, including timely updates to the individualized care plan, is essential.
“Mr. Adams has therapy orders that include physical therapy with recommended use of a front-wheeled walker; occupational therapy recommending minimal assist during toileting; and speech therapy recommending supervision during activities of daily living. However, Mr. Adams is refusing his walker, goes to the bathroom when he pleases and states, ‘I don’t need all of these people looking over me. I am 87, for goodness sakes!’”
Myth #9: Patients must follow recommendations made by therapists.
Fact: Skilled therapy providers make recommendations, not orders, and our recommendations do not supersede a resident’s right to make his or her own informed decisions.
Navigating the informed consent process can be complicated. However, the Rothschild Foundation has created a beneficial tool to assist with navigating the process. Steps include identifying the individual’s choice, discussing the options, determining how to honor choice, care planning for the choice, monitoring and making revisions, and reviewing as part of the quality assurance and performance improvement (QAPI) process.
Renee Kinder, MS, CCC-SLP, RAC-CT, is Director of Clinical Education for Encore Rehabilitation and also serves as the Gerontology Professional Development Manager for the American Speech Language Hearing Association.