The rehabilitation component of skilled nursing has grown and developed into an established service area for long-term care facility operators over the past two decades. Yet despite its maturity, it must continue to evolve if rehab providers are to capture the burgeoning patient volume and revenue potential that exists, industry observers say.
Created by a surge in demand for post-acute rehabilitative care, skilled nursing facilities have become the standard referral center for victims of stroke, neurological trauma and other debilitating conditions. Typical therapeutic services include physical therapy, occupational therapy and speech pathology. Patient stays usually run from 30 days to indefinitely.
While rehab has become a reliable revenue generator for LTC facilities, industry dynamics aren’t standing still. Medicare and Medicaid policies are continually in flux, health plan coverage criteria undulates and patient demographics are shifting toward the baby boom generation.
Expansion plans
These realities, authorities say, present both challenges and opportunities for providers in redefining and expanding their rehab service offerings.
As a parochial matter, long-term care facility operators and rehabilitation professionals have various options to expand their service offerings, improve clinical efficacies for therapies and capture a broader population of patients, says Mark Richards, vice president of clinical education for Reno, NV-based Accelerated Care Plus.
“There are a variety of providers in the long-term care industry who are focused on quality care and are continually seeking new ways to improve outcomes,” he said. “What we have seen is that there is a strong correlation between a provider’s quality of care and a company’s overall business performance. The more innovative providers recognize that connection and are shaping their organizations around that philosophy.”
Marta Keane, vice president of rehabilitation for Columbia, MD-based Encore Healthcare, has seen significant changes in the industry over the past decade and predicts more will occur going forward. Encore is a management company with a portfolio of 26 skilled nursing facilities and five long-term acute care hospitals in 10 states. Besides being a vice president of rehab, Keane is a certified speech pathologist and audiologist.
“The most important change I’ve seen is the move to the prospective payment system in 1999,” she says. “At that point [CMS] made some changes to the number of groupings they had and there are plans to change them again, perhaps this year. I am also seeing governments getting squeezed by the shifting economy and Medicaid reimbursement is being impacted. That will have a definite effect on long-term care patients.”
Mary Pidich, vice president of quality assurance for Las Vegas-based EnduraCare Therapy Management, says rehab providers have done an admirable job, considering the coverage and regulatory limitations.
“Over the past decade, the rehabilitation profession has demonstrated the ability to not only survive wide-sweeping regulatory and payment restructuring but to successfully deliver the highest level of therapy in an efficient and outcomes-focused model of care,” she says. “Under PPS, rehabilitation professionals learned to adapt the model of care for Medicare Part A patients based upon a possibility of 44, and later on, 53 possible patient level of care and payment categories. For Medicare Part B services, we have had to cope with a therapy financial limitation not based on level of care or need but only on a dollar amount. Physical therapy and speech therapy services have a combined capitation of the same dollar amount as the occupational therapy limit.”
On the whole, rehab professionals have done a commendable job working under the regulatory limitations, adds James Hummer, senior vice president of operations for Alexandria, VA-based SunDance Rehabilitation.
“Providers are increasingly adept in managing PPS requirements, as well as working with other payer requirements under managed care, Medicaid and private pay,” he says. “Providers are increasingly able to furnish a range of interventions from one-to-one treatment to group therapy.”
Besides policy and reimbursement, demographics are another key influence on post-acute rehab, Keane says, calling the boomers “the bubble” generation.
“This new group of seniors is postponing retirement and they’re looking to stay in their homes instead of moving to Sun City,” she says. “These are people who don’t need long-term rehab—it’s more knee and hip replacements with co-morbidities. Nursing homes need to change their image in order to attract this population. Facilities can formulate an integrated approach for PT, OT and speech therapy and provide a plan of care in conjunction with nursing to meet all their needs. Rehab 25 years ago was more for SNF residents – now it’s for preparing patients to go home.”
Assessing therapy needs
Clinical demands on therapists are also sharpening, says Accelerated Care Plus’ Richards.
“Therapists are becoming more sensitive to, and in tune with, the need to provide therapy services supported by research. CMS and private insurers also have increased their expectations regarding evidence-based therapy interventions.”
In order to assess whether they are maximizing revenues from rehab patients, facility operators need to take stock of their service levels and whether they are meeting the needs of patients and payers, Richards says.
“The question really is, are providers adequately meeting the therapy needs of those they serve?” he says. “If the focus is on thoroughly treating patients in accordance with the regulations, the therapy revenues will follow. In that regard, the therapy profession is making progress by offering more comprehensive services to meet the complex needs of skilled nursing facility residents—more involvement with wound care, incontinence, pain, as well as providing better care to increasingly more complex patient presentations.
“There is an opportunity to improve the bottom line by increasing therapy efficiencies via the use of medical technologies, such as electrical stimulators and implementation of electronic documentation and billing systems. The appropriate use of technology is particularly important considering the shortage of therapists.”
Martha Schram, president of Aegis Therapies, agrees: “Technology holds a promise for improving the lives of all of us–we must include it in the treatment of the geriatric population.”
‘Engagement tools’
Though not a service along the lines of physical or occupational therapy, computer “engagement tools” can work in tandem with those exercises, say representatives from Centennial, CO-based It’s Never 2 Late.
“Although we’ve been around for 10 years, over the past year many of our customers have started using our systems as a therapy tool,” says Lori Snow, the company’s director of marketing. “Therapists are finding that clients are doing their exercises longer due to the engaging nature of the software and that folks who had previously refused to participate are now getting involved.”
Designed to promote physical and cognitive wellness, the It’s Never 2 Late applications include a variety of virtual activities, including simulated flying, driving and bicycling; touch screen puzzles and painting, as well as speech therapy and memory applications, cognitive recognition tools and dementia engagement.
Company representatives say their systems offer new educational options for therapists, providing activities for outpatient therapy, adult day care and dementia programs. The systems also help facilities meet the CMS F-tag guidelines for activities, quality of life, dignity, self-determination and participation, Snow says.
“Each of these regulations promotes the development of person-centered activities and experiences that identify an individual’s interests and needs and involve the individual in an ongoing program that maintains the highest level of physical, cognitive, and psychosocial well-being,” she says.
Wii and more
Alternative therapies “definitely have a place,” Keane observes, “especially at the assisted living level, where the patients are more ambulatory.”
Integrating simulated programs, which also include the Nintendo Wii system, have proven to be popular with therapists and patients alike, she says.
“The Wii system has been in place in our facilities for about a year and a half and it has been very exciting,” according to Keane. “Residents love it. One resident who was a golfer but could no longer hit the course could play this. As a result of the physical motion involved, he can now feed himself.”
Alternative physical activities such as yoga also hold an important place on the therapeutic menu, Keane adds.
“Yoga is a key piece of physical, spiritual and emotional wellness,” she says. “What we have to look at is providing very individualized goals. Therapists have to make sure that everyone who participates in yoga has goals that can be met.”
Linda Karacoloff, vice president of clinical services for SunDance, believes providers need to strive for a balance between conventional and alternate types of therapies.
“The focus of care continues to be providing skilled, medically-necessary services as is required under Medicare,” she says. “However, all other approaches and practices can be woven in, as long as they meet the goals under the established skilled therapy plan of care.”
_____
Rehab trends:
The rehabilitation field is filled with promise for long-term care facility operators as new technologies and concepts offer a chance to engage patients, increase referral volume and maximize revenues. Bob Latz and Alla Onitskansky, executives for Las Vegas-based EnduraCare Therapy Management, identify here some of the key trends that are currently happening, as well as projections for the future.
CURRENT TRENDS
Programs
-Nintendo Wii
-Pilates
-Weight lifting for seniors
Technologies
-Electronic documentation
-Web-based software for case management
-Electric wheelchair usage for patient assessment
Policies/Clinical philosophy
-‘Zero-lift’ rules for staff
-Therapy effectiveness measured by outcomes
-Prevention of decline (especially important for CCRCs)
-Revenue optimization through outpatient clinics and home health
FUTURE TRENDS
Programs
-Tai chi – Improves endurance,balance and posture to make the body more efficient. Utilizes low impact, smooth exercises. Tai chi can be billed under “Neuromuscular Re-education” (97112) or “Gait Training” (97116).
-Yoga – Improves balance, sleep, arthritis, diabetes, hypertension, anxiety, chronic pain and breathing difficulties. Helps to prevent falls.
Technology
-Robotic devices for patient transfers
-Virtual reality to simulate home environments
-Computer-based cognitive training programs in recreational therapy, which appears to have a positive effect on outcomes in early studies.
From the April 01, 2009 Issue of McKnight's Long-Term Care News
