The long view

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Nursing home company reaches $2.7 million settlement in therapy billing case
Nursing home company reaches $2.7 million settlement in therapy billing case
It's not quite the same as swarming the racks for the latest summer dress or swimsuit fashions, but providers definitely have made short-term therapy all the rave.

Boosted by generous Medicare reimbursements and fawning media coverage, short-term has earned its spot in the sun.

But savvy providers also have not taken their eye off more traditional, longer-term therapy services. While they might not provide the quick payoff that comes with short-termers, long-term residents are still a major source of business and care focus for most operators.

“I'd certainly agree the buzz is how do we attract the short-term, quick in-and-out patients. But there's also the emphasis of taking care of [longer-term] residents in the nursing home. It's an obligation,” says Linda Kurland, vice president of clinical services for RehabCare, St. Louis. “From a financial perspective, the emphasis is what the Medicaid reimbursement is. The model for efficiency, which is done in the vast majority of states, is in a restorative program.”

For patients with a decline in function, or the looming risk of one, therapy “will pick them up,” Kurland notes.

“Even for patients who have dementia. Maybe they're not going to learn new things, but therapists have a keen set of teaching sills to reduce the speed of decline. They can benefit from those repetitions. We can guide them through to at least maintain their function or, in some cases, improve.”

The clientele is there, and will continue to be there, says Peter Clendenin, executive vice president of the National Association for the Support of Long Term Care.

“The majority are long-stay, chronologically ill patients whose length of stay is at least six to eight months,” he says. “They have a high degree of impairment, with several chronic conditions and high ADL needs. As a result, going home, home care or assisted living aren't much of an option. And two out of three have cognitive impairments, so they need assistance all the time there.”

He says the short-term therapy rush has proved to be an interesting phenomenon.

“The nursing home industry for many years was accused of purposely keeping people longer than they needed to stay. I think those days are over,” he explains.

Stroke is the condition that could trigger short-stay help, but it also could be an event that winds up requiring long-term assistance, Clendenin notes.

Helping hands

Kurland says a restorative nurse aide is the key to many aspects of care, whether it's treating residents with falls, incontinence or other risks.

“We develop a plan the nurse aide carries out on a continuing basis, perhaps taking a walk and taking cues so they don't lose the progress they made with us. In my way of thinking, that's the way to meet these patients' needs, and be efficient as well. A therapist can be involved in a short course of therapy, and then the patients is discharged to a restorative program, which is more economical.”

She said she doesn't see the traditional model of long-term therapy changing much, though some of the equipment has. The use of e-stimulation to promote better swallowing, ultrasound equipment and diathermy are new wrinkles to older, long-term care routines.

“What Medicare and other insurance providers are looking at is they'll be glad to pay for those services that are proven to be efficient, but they're not willing to pay for those that are not efficient,” Kurland says. 

“It's almost like the short-termers are an addition to the business model, which does not exclude the long-term.”

Express experience

Strong therapy departments can “put more tools in the toolbox to more effectively treat patients,” notes Mark Richards, vice president of clinical education for Reno, NV-based Accelerated Care Plus. Treatment for contractures, wounds, chronic pain management and other conditions that require a longer view can be enhanced with modalities such as electrotherapy.

His firm offers different forms of electrical stimulation, an ultrasound machine, short-wave diathermy machine and light therapy.

“We kind of scour the literature and develop applications for each of these,” he says. “Every athlete is treated with modalities, but when we get to long-term care, it's like, ‘Oh, it's not good enough.'”

Express experience

Velvet Mayes knows about the short-term craze firsthand. The vice president of marketing and sales for regional therapy provider Hallmark Rehabilitation, her company operates 25 “express recovery units.” That leaves the majority of the company's 93 facilities without them. 

“A modality program used in a traditional therapy care program can get you extended results with your residents,” she says. “It's a ‘while you were sleeping' type new approach to something that was out there. It's just enhancing the hands of the therapist through specialized training and protocols.”

It's not uncommon for one of her therapists to discover ultrasound machines not being used or specialized machines broken or calibrated incorrectly, she said: “It's a new concept in long-term care so not everybody's doing it.”

Providers must not overlook some basics, she added. A facility trying to impress current and potential residents has to have an appropriate location, and sufficient space.

They also must have basic therapy equipment such as a table, mat, parallel bars, stairs and occupational therapy equipment, Mayes reminded. The final basic “must” is a skilled, reliable workforce – preferably with some way to track outcomes.

Although one of the largest eldercare therapy companies in the country has made headlines by creating a division of short-term therapy units, a top official said it is in no way forsaking traditional care.

“While there is a heavy emphasis on short-term rehab, there are many, many who live in facilities, and will continue to live there,” says Aegis Therapies' Mark Besch. 

Deserving the best

“Those people have needs as well,” he continues. “Many of them, because of disabilities or loss of function, may not be able to fully regain or rehab, and they the certainly deserve our attention and the best rehabilitation efforts we can give them.

“It's also important to realize this is a changing population, and as they change, they may develop new needs and new conditions.”

He cites a three-pronged approach in his care philosophy. The focus, he says, must go beyond restoration to include compensation and adaptation.

“Compensation is teaching individuals new strategies and new ways to accomplish a task. It could be as simple as using a walker to get up and around, or some specified technique for swallowing if there are swallowing problems.”

Adaptation is changing the task. For the individual who might have difficulty navigating around a room because of visual difficulties, the lighting, or color of the floor or furniture arrangement might be changed. 

“You no longer expect the change in the person themselves but rather the environment or task,” he explained. “As a therapist, we need to realize we have things to offer.”

He said measuring the quality of services and care will become more important than ever.

“The really forward-looking operators are going to realize CMS is clearly moving down a path of pay-for-performance,” he said, so the ability to ensure quality ultimately is going to impact reimbursement and things like census and admission.

That means providers are going to have to know their residents' conditions, and staff members' capabilities, better than ever.

Paying closer attention

Vigilance is needed, attests Kim Polite, the director of rehab services at Island Nursing and Rehab Center in Holtsville, NY. She said she tries to screen more residents more often to find those who have stalled or reversed their functioning progress:

“I'll pick up those patients and try to get them back to their prior level of function. They might come off therapy and wind up not walking with the CNAs. All of a sudden, somebody who used to walk 300 feet is walking 50 feet. That's just not fair to them.”

And when it comes to good business, Polite reminded practitioners to keep a closer eye on time worked.

“A lot of times we (therapists) don't bill for all the stuff that we do. We're asked to do this, and that, and we do it out of the goodness of our hearts. We'll just say bill 50 minutes and we're actually spending 75 minutes with them. You're doing it anyway, so why not bill for it and see if we can get into a higher category?”