Ethics of Productivity

I had recently submitted an article in the Advance for PT/PTA regarding. Search "productivity" at the archive articles%0d%0aTom

Here is my problem with productivity. I too work in a SNF where patient care is supposed to be "number one" but never is. I have tried relentlessly to search for this topic and cant find an answer. So here it is:

Is it ethically okay to bill for your documentation time? Weither or not you res is present?

Because my company keeps pushing for more units. Which in reality is more money and they keep pushing me to bill for documentation time. Ethically I feel this is wrong! And even if I am wrong then under which area do you bill that under? Thats what makes me believe twice as much that its unethical.. someone please respond!

Being relatively new to the SNF setting as an OTR after spending time in the mental health system and ALF setting, I am feeling the frustrations of all of the comments above.  As a mother to a young child, I switched back for working at an ALF full time to part time OTR at a SNF working PRN which was great.  Then I moved to Hawaii where there is no OT school or PT schools out here.  So basically, there is a shortage of OTs and PTs out here.

I was able to work part time for a national contracted company but the demands of the job was just too much for me.  I was treating 12-14 patients a day all concurrently to just get the work done.  There were 4 other staff holding the same caseload also.  I decided that I was not really benefitting the patients so I left hoping for a better work situation.

I was able to negotiate working a 4 day week.  Unfortunately, being the one not able to say no, I landed up working nearly 5-6 days a week to cover the caseload.  For me and my COTA who is full time and me being 30 hours a week, we have almost 16-18 hours of direct time between the two of us daily.  The workload is just killing me and her.  My manager wants us to do groups daily to cover the patients but her and I (behind her back) have told her that we will do what we can and that's it.  We see who we can see and give them fair treatment.  If we can't see them we can't.  We get a lot of slack because we are supposedly not holding up our end and missing RUGs levels as a result.

In the SNF industry, it is so easy to see that the potential for financial gains blinds the greater outcome of improving the lives of the clients we work with.  I stick strong to my ethics and I can only do what I can do, and the rest is up to god.  I will not bend just to satisfy the needs or desires of the company.  We as OTs have to stay strong to our values, if not, we will face future problems as a result!

I have recently quit a job because I was asked to continue therapy services where the patients had already met their goals.Even the OT in charge was going along with the Administration. Since it was an ALF and they were in need of supervision and "paying extra" To recieve showers treatment for ADL's were limited.

I am a very productive COTA but if the patient tx's aren't there we can't pull them out of our hat!

I think we need to be careful about whether what we are doing is actually goal related, or just busy work for units!

I also would encourage the OTR's to make sure the patient knows what their goals are at the initial eval as many I spoke to were surprised to find ADL's as part of their POC.

Many times the patient has goals in mind that are more realisitic than our typical protocol.

Hi

I agree with all of you regarding the productivity issue!!

I really do feel that it impacts everyone negatively and affects patient outcomes.

What makes it especially hard is being in a managerial role and trying to maintain a balance of ethics and finance.

We all are in an ever changing world of OT... and as much as we all like to do the best for our clients we also have to remember that this is our livelihood....

I still do hope that we can acheive a happy medium where we are providing the best possible care to our patients and still being profitable.

Yes, productivity and ethics appear to be conflicting priorities in the current clinic. When I hear stories of a COTA required to complete 600 minutes of treatment within a 480 minute day, I wonder if any of the treatment was based on the patient goals, or just activities to capture minutes. I'm glad to hear there are still some OT's out there that continue to stick to their priorities and work in an ethical manner. Our number one goal is patient care based on their needs, not just busy work to capture minutes.

This is a huge topic and one quite timely for me.  I just resigned my per diem position because I can no longer reconcile ethically with the treatment expectations under PPS. ... and I am concerned about what I see happening in long term care facilities.  

Recently, I had a patient who was too ill to participate and another who flatly refused.  I was instructed to find a way to provide treatment so that the department's productivity would not be negatively impacted.  I asked, "So we no longer provide patient focused care?" and the reply was "No!"

Good intentions and outcomes aside, this current system is flawed.  I personally made the decision at that time to leave my position at the end of the year to pursue work as an occupational therapist providing occupation-based, client-focused therapy in service to my clients.  I am not certain what that will look like at this time but know deep in my soul that it is the right thing to do.

I remember Barbara Kornblau, speaking in her position as President of AOTA, stating that occupational therapists are life architects.  We empower our clients to create and contribute in whatever way has personal meanng for them.  We assist them to heal themselves through engagement in occupations that are life affirming.  

Our roots are not problem-based treatment, rather life affirming and strengths-based.  That is not what I see in our current healthcare system that is based on a medical model.  How did we stray this far off the path?

So, call me old fashioned, unrealistic and perhaps, even crazy- but I have decided to return to a more holistic practice of occupational therapy.   Stay tuned!

I agree that productivity has become quite a hot topic again.   I do believe that 'productivity' is a misnomer. In that, I mean there is a difference between billable time and productive time.  When I reference productivity, I am referring to the amount of time a therapist is billing for patient care.  Having personally worked in a variety of settings for varying companies, I can comfortably say that every company has varying expectations, ranging from 75% - 90% per treating therapist.  Does anyone know if there has been any research to demonstrate a correlation between productivity and positive patient outcomes?

I recognize that therapy is a revenue generating service in most settings.  This is America.  People who own stock in a company want to see a return on their investment.  I dont' believe there is anything wrong in turning a profit.  We all enjoy paychecks and dividends on our investments.

However,  I believe every therapist and assistant MUST assess the needs of the residents and provide the SKILLED OT INTERVENTION that address individual needs to reach their goals.  It is our responsibility as therapists to do the right thing by the clients we work with!  Providing concurrent treatment and/or group treatment upon request of someone who is neither legally or ethically liable for the service given is not a valid reason to do so.  Likewise, a therapist who simply provides an activity to engage their clients which will incidently benefit any client is not a good thing either - when billing for skilled intervention.  I believe each therapist needs to look at their caseload, and ask themselves.... What do I need to do to get my client from point A to point B?   What needs can be met via group treatment (for those in LTC, please pay attention to how Medicare defines group)  Which clients need to be 1:1?  Which clients can I effectively work with concurrently towards their goals?

The skills of each therapist varies.  Some can multi-task well, others not as well.  Some therapists who are newer to the field may struggle with 1:1 treatment.  In the end, however, it still remains the legal and ethical responsibility of the therapist who has their license on the line.

I think it is important as well, to be sure that therapists are billing appropriately.  Perhaps productivity is low because billable services are not being captured.  Are therapists monitoring  treatment minutes provided such as for Med B's?   sometimes, missing another billable unit for just a minute or two for 1 or 2 patients a day can have a huge impact on weekly productivity.  Concurrent treatments may be beneficial, but under the Medicare program, 60 min of patient care is the most that can be billed for and would need to be split between the treating therapists.  That is a 50% loss of time for that one hour of time for both therapists.  Does this mean that as clinicians, we stop doing co-treatment when the client needs it?  I sure hope not!

One thing therapists can do, is really analyze where they are losing time.. why arent they reaching the target that is set for them for their setting.  Are there tasks that can be delegated to an aide or other staff person?  Are there systems that can be developed to help make work flow more smoothly?

A huge challenge I found in working for a contract agency in a SNF setting, is that the expectations of the facility far exceeded what the contract agency allowed for in non-billable time.  This is the time to become assertive with your agency, and have them negotiate with the facility so that expectations are fair, and/or time spent on other things the facility wants can perhaps be billed for on a separate line, and become factored out of the productivity formula.

It is sad to see many therapists do things to increase their productivty numbers and/or revenue targets without putting patient care first.  If our 'customers' dont show the benefit from our intervention, it will have a snowballing negative effect on the entire profession.  Billing fraud is a federal offense!  It may be tempting to add time in, but willingly doing so can result not only in losing your job, license, career, but in jail time.  I dont know anyone who wants that.  With the technology we have today, there is no reason any therapist should not access state licensing information and CMS website for clarification on proper billing practices.  Relying solely on an employer for this information is no longer good enough.  Regulations change regularly.  If you have a license to practice OT, and bill for your services, it is your responsibility to remain current!

I would recommend that when any therapist interview for a job, ask what the expectations are for productivity.  We all have either worked before or have done clinicals.. so we should all have a feel for what we are able to do.  If employed and stuggling, analyze your situation and speak frankly with your supervisor about it.  Take responsibility for your caseload and try to meet expectations.  If the fit is not right, there are always other opportunities out there!

whew....  a lot of thoughts running, hope they make sense and help someone!  I love OT!  and so do my clients!!!

Lisa