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Striving to Be a DPT

My First Rotation: The Skilled Nursing Facility

Published July 10, 2015 3:14 PM by Jocelyn Wallace

My program is unique in that we do our first full-time, 4-week rotation at the tail end of our first year. My first, along with the rest of my classmates, was in the SNF setting. "SNF" stands for skilled nursing facility, or nursing home. I greatly enjoyed my experience in my SNF, which was a 196-bed facility that had approximately 50% long-term care and 50% short-term patients.

The majority of the patients seen by the rehab department were short-term stays for diagnoses such as complicated joint replacements, falls, and neurological injuries. Many of the long-term care residents had been there for years for general failure to thrive, while others had no option to go home due to a need for care.

My biggest takeaway from my experience in the SNF was a general frustration with the setting. Many students are hesitant in the first place to work with a geriatric population. I can't deny that I wasn't thrilled, myself.

However, I enjoyed the population more than I expected. I bonded very well with a lot of the patients and my days were filled with smiles. The patients I saw ranged from 42-101; hardly a boring population! My general frustration came from the way it seems physical therapy is practiced in this setting.

My education and experience thus far have shown two major themes in helping patients see gains; specificity and overload. The majority of the patients in the SNF were given high-repetition, low-weight exercises and rarely seemed challenged. If a patient did not want to try a heavier weight, the efforts to convince them otherwise were minimal.

It seems like there is a lot of room for improvement in how PT is practiced in this setting; however, I realize that it is complicated by billing and insurance restrictions. Either way, I'd like to see changes in the setting during my career.

On the positive end, I have gotten much more comfortable working with patients and doing all sorts of psychomotor skills. I was very pleased with the experience and am excited for my upcoming clinical experiences!

Does anyone have any thoughts on the strengths and weaknesses of working in a SNF setting and how physical therapy is provided?

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I did my last clinic at a SNF and came back as prn once I graduated. I love it! The biggest skill required is patience. You will have patients that will be mean due to dementia (patient hit and cussed at me yesterday), confused and not understand, or just completely checked out and non verbal. But you'll also have really hard workers who want to do their best. Even just being prn, there are long term residents who aren't my patients anymore but still get excited when they see me and want to give me hugs.

I have been at a nursing home where every patient is at the highest rug level and productivity was 92%. Impossible. My current SNF has 85% productivity, a rehab tech, and many patients are seen for 30 minutes. It's based on activity tolerance.

I have seen some terrible nurses at nursing homes and I honestly believe rehab has saved some lives by not letting patients fall through the cracks and making staff accountable. I feel like I'm making a difference in the lives of my patients, moreso than in acute or outpatient. I brighten their days and they brighten mine.

Grace Thalia June 13, 2016 7:13 PM

I work in an SNF and its a terrible place to be in especially if you are the “last hired” person. It doesn’t matter that I’ve been with the company 6 years.It just so happened that my 2 therapist co workers had been there longer than me. The company has this archaic rule that last person hired is the first person to go home when the census is low. The census in my place has been crappy for a long long time and i had been sent home more times than I care to count. It also doesn’t help that my facility is rated only 2 stars so the physiatrist is refusing to send more patients until the ratings goes up. I’ve been forced to use PTO so I could make up the lost time and get paid a full day which is 8 hrs in my place. I cant take a decent vacation for fear that i might use up a lot of PTO and have nothing left to cover for the slow days at the SNF. I pleaded my case several times but the HR manager each time would just flash the rules and regulations in my face.My co-workers are willing to “rotate” who’s turn it is to go home but the DOR and the higher ups will simply not allow it. The quality of the patients also has gone down the drain especially in my case. My co workers get all the high level Med A patients since their “quota” needs to be filled in first and I end up with the “bottom of the barrel”patients in the LTC section with little to no potential at all. The admissions director is no help either. She doesn’t give a hoot if she gets any patients or not since she is already paid in full as a salaried employee. Most of the time Im at our sister facility now but its been slow there too on several occasions. Guess who gets sent home? Im just sick of the whole thing. I would like to go back to working in a hospital. So to all you new grads thinking of working in an SNF? Dont do it or you will be royally screwed!

joey, PT June 6, 2016 9:58 PM

Hello Everyone !  

My knowledge about SNF setting is not vast so I want to know more about it. How does an average day look like in the  life of a PT working in this type of setup ?  What type of personality and skills are needed most in this setup ? In terms of  assessment /evaluation and documentation which software's or tools are used ?

          It would be a great place to learn about mixed perspectives and perceptions.  

Nitika Manhas, Pediatric - PT March 3, 2016 7:05 PM

Great article. Keep writing and don't worry, there are great places to work out there, it just takes some time to find them. I also write about the frustrations of therapy. Feel free to connect on LinkenIn or email  Keep it up!

Justin Johnson, SNF - DPT, N/a November 11, 2015 10:00 AM
Bellingham WA

Hi Jocelyn

I linked to your post in my blog post about the recent WSJ article here .  I too hope to see changes in this setting during my career.  Strengths in the setting - making a huge difference (I do TCU/SNF and OP, with some LTC as well); great clients/ patients.  Weaknesses: the current billing system (and for OP, not being able to opt out of MC); more than a few companies that seem to focus on productivity and profit before people (patients and staff!).  Obviously the strengths outweigh the weaknesses for me as I'm in the setting - I'm in a great location as I note in the blog post!

David Gillette September 7, 2015 11:16 AM
Twin Cities MN

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September 7, 2015 11:10 AM

I see a few FT PT's, otherwise prn PT'S  and/ or PTA's. Documentation time is inadequate, training for prn workers on ROX IS inadequate, there are not enough laptops for all the providers on any given day. Even FT providers work through lunch and stay late to complete documentation. Fortunately, the DOR insists that we bill for the time spent, but especially for a prn worker like me the learning process is long. The minutes expected in exercise for patients is often not realistic. Confused patients resist exercise. When patients get a visitor in the middle of a therapy session they understandably want to visit.

Pam , SNF - PT, Avamere Rogue Valley September 3, 2015 4:53 PM
Medford OR

 Such an underserved population!   Too many PT's just going through the motions and doing the minimal to get through the day!   The frustration level is high and so  much value is placed on productivity of the therapist and minutes for the patient. So many older patients are put on high RUG levels that are not able to tolerate the high minutes. How many 85 -90 yo residents are able to focus and exercise for 75-90 minutes?   I'm in my 50's and am tired after 45 min of gym/exercise time.  Studies show that the optimal workout time last approx. 45 minutes so only makes sense to keep RUG levels at mid level

robert August 29, 2015 12:53 PM

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