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Toni Talks about PT Today

The Skilled Nursing Facility Conundrum

Published September 2, 2015 4:40 PM by Toni Patt

Last week I was involved in a discussion regarding membership in the APTA. For once the topic wasn't new graduates but therapists who were members but no longer are. The question was, what would it take to bring them back in? What do they value? I responded by describing how a SNF functions. Fix that chaos and they'll return.

SNFs are unique. Their purpose is to provide rehab for patients who can't tolerate three hours of therapy and can't return home. They are usually part of a nursing home because those patients also require nursing. The crux of this dilemma is for those patients, therapy is a priority and reimbursement is based on therapy.

Maybe in the beginning it worked. Now we have the bare minimum of staff doing the best they can to provide quality care. SNFs are staffed heavily with PTAs. The PT primarily does evals, re-evals and therapist summary notes. Productivity requirements hover around 90%. That doesn't leave adequate time for documentation.

Some facilities do point-of-service charting, which basically means spending time inputting data into a device rather than with the patient. Some payers don't want point-of-service documentation because they are paying for therapy time, not documentation time. I worked, briefly, at one place where the only way to meet the various demands was to work off the clock, which is illegal. Thus why I say I only worked there briefly.

Equipment in SNFs is limited. There is little capital budget for purchases. If something breaks, there often isn't money to replace it. DME for patients is also problematic. If the patient's insurance can't be billed, the patient will either receive something off the shelf or have to wait until going onto Medicare part B. No facility wants to pay for DME or equipment out of their reimbursement.

SNFs do not pay staff well. This is true of both nursing and therapy, although therapy fares a little better. Lower salaries aren't going to attract quality workers. Nursing care suffers. Medicine and medical supply levels are strictly monitored.

Changing this means changing legislation. The APTA would have to lobby, and lobby hard, for those changes and that costs money. Currently those lobbyists and that money are focused elsewhere.

The problem is SNFs are only one piece of the puzzle. Similar issues exist for home health, pediatrics, inpatient rehab and everywhere else PTs work. Thus we have one very large reason PTs and PTAs drop their membership in the APTA. They don't see any value.

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One reason to hire PTs over PTA to do the actual treatments is that many of them are better-able to do on-the-spot problem-solving and make daily changes in the treatment programs, which should be needed if the pt is adequately (instead of minimally) progressing. Doing the same thing day after day is only needed if the pt is not getting adequate therapy to be progressing. Riding on a bike is not considered "skilled PT" and should not be what their therapy time is being spent doing. One place where I worked had extremely high level PTAs and there was very close coordination with the evaluating therapists. This facility was known for their excellent results, and pts moved through their dept pretty rapidly. Point-of-service wasn't yet being done there but most therapists and assistants were working with their patients most of the time, rarely having time to chart when with the pts. A lot of education can be done while a pt is exercising, improving their ability and desire to continue their therapy on their own time, in their rooms.

Camillee, geriatric and lymph - PT September 10, 2015 9:39 PM

SNF's tend to pay higher than hospitals.  Hospitals have better benefits.  As for outpatient it depends on the area and the owner.

Having large numbers of PTA's in a SNF saves money, it is strictly a business decision, why pay a PT when the reimbursement for services is the same for a PTA.  

The equipment issue is a definite problem, so many patients fall through the cracks and do not receive the DME they need to function, but it is a business decision.  

Patients (and therapists) who voted for their national legislators and leaders of this country can vote them out.  It is the voters who have created this mess with Medicare and this is the result.  So I say live and work with the decision that was chosen by the majority or make a change for the future.

Point of service documentation is a problem but if a patient is riding a bike should a PT or PTA be holding their hand while they do it?  I can chart and monitor a patient from 3 feet away.  More involved patients will need more hands on so charting is done later.  Not a big deal.

"Lower salaries aren't going to attract quality workers"  False.  People do the work they love because they want to.  I have volunteered, so that would essentially put be below a quality worker in this case.  

There is more to work than salaries.  Time off, flexible scheduling, etc.  How about those PT's that work in a disadvantaged area (taking a lower pay)so their student loans get repaid faster, are they not as qualified as other PT's?

The APTA is worthless for most of the working therapists.  When something is not working therapists will usually change what they do.  The APTA is not working so what changes are therapists willing and ready to make?

J M September 3, 2015 10:03 PM

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