SNFs Could Safely Embrace Group, Concurrent Therapy Under PDPM — as Long as Residents’ Needs Back It Up

The arrival of the new Patient-Driven Payment Model (PDPM) on October 1 has created a flurry of changing operational strategies — and a reframing of how operators and staff track clinical outcomes.

One of those shifts has been the rise of group and concurrent therapy services, which multiple voices have identified as a key potential area of expense savings in an era where the model for Medicare payments changed drastically overnight. Instead of the old volume-driven system, PDPM creates a specific treatment-to-reimbursement pay structure based on individual resident needs.

But while some therapists and regulators are rightfully skeptical of any sudden spikes in group and concurrent services, at least one leader in the space says that there are reasons to embrace the change — as long as the residents’ needs back it up.


“If asked to do group therapy and concurrent therapy, don’t just say no if you haven’t done it or don’t like to do it — or because you’re worried about it decreasing your hours of work; that’s not being patient-centered,” Ellen Strunk, owner and president of Rehab Resources & Consulting, Inc., said during a recent webinar co-hosted with Skilled Nursing News and Optima Healthcare Solutions. “If there’s a clinical reason that the patient is not appropriate for group therapy, then we need to clinically justify that to our team.”

In the immediate wake of the PDPM shift, several companies made headlines with therapy layoffs and reductions in hours; Genesis HealthCare (NYSE: GEN), for example, confirmed letting go of 585 rehab employees in early October, SNN reported.

Though the Centers for Medicare & Medicaid services installed a 25% cap on group and concurrent therapy programs, operators have been cautioned not to “overcorrect” their practices, which could attract the attention of the Centers for Medicare & Medicaid Services (CMS), Kara Gainer, director of regulatory affairs at the American Physical Therapy Association, recently told SNN.


Despite the initial concerns, a quick pulse check based on how providers are maneuvering through the new model revealed that 72% of the webinar’s listeners feel that PDPM poses a difficult learning curve but that overall progress is “going well.”

Section GG, defined as functional and cognitive scoring, is one of the more confusing newly important categories for providers. During the presentation, Strunk advised nursing and therapy staffs to collect in-depth data and documentation related to patient functionality throughout the duration of their stay — so that an accurate measurement of a resident’s “baseline abilities” and health can be captured as a reference for their entire stay.

Staff should maintain a keen awareness of rating scale definitions, especially when it comes to the resident carrying out activities independently and as safely as possible. It’s also necessary to document “how much assistance is required when the patient is allowed to perform the activity on their own,” Strunk said.

In particular, for the new therapy model, ensuring that the plans of care reflect individual patient needs is essential, regardless of reimbursement probability.

In order to achieve that direct link between care plans and services, Strunk suggested asking ongoing questions such as:

  • Does the patient need closer monitoring, such as taking vital signs more consistently?
  • How much assistance is needed for the patient to stay on task?

Group therapy definitions are still in flux, and Strunk sees this change as a benefit for therapists — and believes they will have more flexibility in how the definition of group can be applied to treatment. Suggested questions for patient inclusion include:

  • Can this needed intervention be delivered in a group therapy setting — and, if so, does it offer a better value to the patient than doing this treatment individually?
  • Is the patient willing to participate in a group?

Billing confusion under this new model has been a source of frustration and anxiety for operators and clinicians. Medicare released claims processing manual revisions last week, but all of the new billing information under PDPM has not yet reached providers. In fact, many operators don’t yet know if their managed care partners have switched to the PDPM model or intend to stay with the old Resource Utilization Group (RUG) system, Strunk said.

“This has created extra work for those who are completing assessments defensively,” she said

A good rule of thumb is to triple-check all documentation to justify coding in several categories of care. Strunk advised operators and billing staffers to check CMS’s PDPM web page frequently to look for new updates, read through the fact sheets, and comb through training presentations to clarify and remain up-to-date on any changes involving this new model.

Editor’s Note: An earlier version of this story mischaracterized a statement about Plan 4405 and the Review of Medicare Services attributed to Ellen Strunk. SNN apologizes for the error.

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