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PT and the Greater Good

The SNF Rehab Model Must Change

Published July 15, 2014 4:56 PM by Dean Metz

I've learned immense amounts about what my American PT colleagues are going through just to work these days. It disheartened me at first, inspired me next, and now has propelled me to think more creatively. I think it may be time to throw out the baby with the bathwater... and the tub... and the sink... heck let's just rip down the house! The SNF rehab model doesn't work! If owners can't make a profit without professionals having to work off the books, overtime, and destroying their professional lives... it is a failed business model, plain and simple.

I started thinking about this because there are very few SNF rehab facilities here in the UK. Our town (population 283,000) has one with a capacity of about 20 people. Mostly acute TBI patients, acute trauma patients, and an occasional person with a stroke occupy those beds. Care homes here are staffed mostly by CNAs with some nursing oversight. If rehab is required, it is referred out to community teams (the equivalent of home care).

Where has the American SNF model evolved from? Has it actually been changed to maximize reimbursements? With so many stories of inappropriate patients on program, I seriously doubt it has evolved from patient need or demand! I also seriously doubt the situation will improve as time goes on.

Here is where the APTA can step in and not appear to be working as a trade union! They can ask the important questions, such as: Are the patients still benefiting from this model? Who does this model serve? What possibilities exist for changing sub-acute rehab into a more workable model?

In this way they can support us as professionals, demonstrate our ability to be proactive and leaders in patient care, and have a voice in creating the care landscape of the future. If they want us all to have the respect that comes with the DPT and autonomy, then they can't let us work for free in a sweatshop environment. Who is going to respect us when we work in that fashion?

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Excellent News! Thank you APTA.

Dean Metz July 23, 2014 2:33 AM

Ramil, thank you for your response. I do not doubt for a moment that there are dedicated therapists like yourself and your team who are doing excellent work. I believe that there are even some companies, like the one you describe working within, that have reasonable expectations of their employees. I'm pleased to read that you enjoy and are proud of your work. It is heartening.

Unfortunately, it doesn't take much reading to learn that most SNF companies do not have the same ethic as the one you work for. The response to this particular blog has been overwhelming with nearly 50 shares on social media and many more "likes" as well as personal comments. The majority agree with my statements.

The clinical model works very well or else it wouldn't have lasted so long. That is not enough in a capitalistic environment. It HAS to work as a business model too. So one of two things is going on here: either companies like yours are taking a loss and making enough in other markets to make up for it or other companies are simply money grabbing and not caring what the outcomes to their workforce or their patients. I have a hunch your company is doing just fine which leaves only the other option.

Sincere thanks for joining the discussion! This is a discussion that needs to happen and if some companies are acting unethically and making the rest of the industry look badly, then they need to be taken to task on it.

Just a note of appreciation for all who shared and commented. I'm pleased to have struck something that evoked such a strong response. Now, what are you all going to do about it?


Dean Metz July 22, 2014 2:18 PM

I respectfully disagree with you Dean. With your comment calling SNF/sub-acute rehab setting here in the U.S. as sweatshops and conveyor belt laden is unfortunate.

By the way, I'm a Canadian working in the US, and just like in the UK we don't have much SNF, but it doesn't mean that the US SNF rehab model is not bringing excellent patient care.

The facilities I'm working for have outstanding specialized programs (i.e. cardiopulmonary, neuro, orthopedics, geriatric, and long term care, etc.) and outstanding outcomes with at least 90% going home independently.

We take care of our patients individually, at 1:1 ratio. Most of the therapists, including me, are at 85% productivity with pay rates 3x higher than the cap of a band 7 physiotherapist with NHS.

Overall, I don't see any reason why SNF rehab model in the US must change as what you have suggested. Maybe you are referring to how individual facilities are being managed.

In terms of respect from our patients, we are well respected and in my opinion, respect is a mere reflection of how you treated patients during their episode of care.

Ramil Abenales July 21, 2014 9:39 PM

I've worked in several SNFs.  I wouldn't say they are a sweat shop and some are better than others.  The biggest problem I've seen is SNFs who either admit inappropriate patients or assign unrealistic time expectations to patients in order to generate income.  Other constantly cycle through Medicare part B patients for the same reason.

All the research is showing more therapy is beneficial. Yet we send these patients home in as little as 2 or 3 weeks. Why?  To maximize reimbursement.  

The SNF model doesn't need to change so much as the reimbursement structure.  Ninety percent productivity means I don't have time to go to the bathroom.  

Toni Patt July 17, 2014 7:04 PM

I agree with you completely. It is not to say that there aren't good therapists and some positive outcomes in SNF, but it is a very difficult environment in which to provide optimal patient care. The demands on the therapist are such that getting to know the patients and providing consistency of care that is directed at their specific needs is impossible.

SNF may have been a good idea at one point but corporate greed has gotten in the way.

Christine Hucklebridge, OTR July 17, 2014 9:46 AM

Jason, I believe you have focused on only one part of my post. It is true that there are few SNFs here in the UK, but my point in demonstrating that is to make people aware that we aren't locked into the current model. I'm not necessarily advocating for eliminating SNF rehab.

One of the possibilities that crossed my mind was employing therapists as independent contractors rather than employees. The therapist has more control over how they spend their time and can negotiate fees that account for work that is beyond direct care. This would empower professionals and take some burden away from employers.

The point is we NEED to think differently. Perhaps I should've capitalised WE instead, I for one am tired of soulless corporations telling me what to do.

Dean Metz July 16, 2014 1:28 PM

I have to disagree with this.  The model does work just not in every capacity and not every facility is a sweatshop.

And if you think this is bad wait till the new model moves in where PT departments will be a drain on reimbursements if the patient stays longer than the facility wants.  Right now the longer we keep patients the more facilities make, the opposite will be true soon.  The shorter the stay the higher the reimbursement rate.  

Individual workers have to make a choice to change this within the industry and if there are not enough therapists who stick together and fight (ie voice their concern) the companies do not change.  

I could make a list of companies to avoid but another person may love that environment and the challenge it presents for them professionally.  

I agree the system has flaws (many flaws) but to close them down completely would not solve the issue of care and not all therapists like out patient or home health.  

Jason Marketti July 15, 2014 10:58 PM

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About this Blog

    Dean Metz
    Occupation: Staff Development Specialist
    Setting: New York, NY – Newcastle Upon Tyne, Great Britain
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