Providers Increased High-Intensity Therapy for Skilled Nursing Patients Near Death

As the skilled nursing industry prepares for a shift away from therapy as a primary reimbursement driver, a new study raises questions about the use of high-intensity therapy minutes at the end of residents’ lives.

Between 2012 and 2016, ultra-high rehabilitation services provided to nursing home residents in their final month of life spiked 65%, according to research from the University of Rochester, with overall end-of-life therapy use rising 20%. In addition, residents of for-profit nursing homes were almost twice as likely to receive high- to ultra-high therapy than those in non-profit buildings.

Those findings mirror trends identified by the Department of Health and Human Services Office of the Inspector General (OIG), lead researcher Helena Temkin-Greener told Skilled Nursing News.


“They don’t seem to be associated with changes in resident characteristics,” Temkin-Greener, a professor emeritus at the University of Rochester’s Department of Public Health Services, said. “So the residents’ care needs appear to stay the same over a period of time, but [there are] increases in the use of ultra-high therapy.”

The OIG found that between 2011 and 2013, the overall proportion of ultra-high therapy minutes grew from 49% to 57%, raising general concerns about the necessity of such services. Writing in the study, published in the October issue of JAMDA — The Journal of Post-Acute and Long-Term Care Medicine, Temkin-Greener and her colleagues noted that the OIG identified a hospice resident who asked to stop receiving therapy — but continued to receive physical therapy services five days per week for more than a month.

Still, the OIG’s probes didn’t specifically look at end-of-life therapy provisions. Temkin-Greener’s team analyzed data associated with 55,691 long-stay skilled nursing residents collected between October 2012 and April 2016 in New York State. Of that group, 7,600 received some kind of therapy during the month prior to their deaths.


Temkin-Greener specifically cited the gap between for-profit and non-profit nursing home therapy as a reason for concern.

“That gives me pause. If receiving high- to ultra-high therapy is a good thing at the end of life, then I shouldn’t be seeing such a significant finding, with two-fold higher odds of receiving it in nursing homes associated by profit status,” she said. “If it’s good for everybody, everybody should get it. If it’s bad for everybody, nobody should get it. I’m sure there are shades in between, but I shouldn’t be seeing profit status as an indicator.”

Based on those results, the team concluded that financial pressures may frequently play a role in the therapy decision-making process at nursing homes. Under the new Patient-Driven Payment Model, set to take effect next fall, Medicare reimbursements will no longer be linked to the volume of therapy provided; rather, the Centers for Medicare & Medicaid Services (CMS) will attempt to more closely link payment amounts to the complexity of services that patients receive.

CMS specifically cited the potential for abuse under the old system as a key driver of the payment overhaul, though Temkin-Greener was cautious not to frame the results of the University of Rochester study as evidence of fraud.

“I’m not sure I would call it fraud, because the therapy is provided — it’s not that it’s not provided,” she said. “It’s just that it’s not provided appropriately.”

Temkin-Greener also said that skilled nursing facilities should place a greater emphasis on training staff to identify when patients may be near death, suggesting that some of the end-of-life therapy minutes came from a misunderstanding of individual residents’ ability to recover from their medical issues.

“When a nursing home has more RNs per resident per day, the use of ultra-high therapy decreases at the end of life,” she said. “So that suggests that higher skill allows people to recognize that a patient is dying, actively dying, and not provide ultra-high therapy.”

Written by Alex Spanko

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