Confessions of a Therapist Post-PDPM: ‘You’re Not Valuable to Them Because You’re Not Making Money’

Among the many early takeaways from the new Patient-Driven Payment Model (PDPM), perhaps the most immediate was its effect on rank-and-file therapists who work at skilled nursing facilities.

Almost instantly after the PDPM shift on October 1, Skilled Nursing News received a flurry of e-mails from therapists who were laid off or saw their hours reduced as providers adapted to the new system — which bases reimbursements on resident acuity, and not the sheer volume of services provided.

The federal government framed the shift as a way to reduce the unnecessary provision of therapy minutes for financial gain, which officials asserted was all too prevalent under the previous Resource Utilization Group (RUG) system. But many therapists on the ground have claimed that the pendulum swung too far and too fast in the opposite direction, accusing operators of cutting therapy services to the detriment of resident outcomes.


One of the therapists who sent in concerns to SNN’s inbox agreed to take part in our regular Confessions series, a Q&A feature that offers players in the post-acute and long-term care space an anonymous platform to express their opinions.

This interview has been condensed and edited for clarity, as well as to protect the identity of the anonymous therapist.

Want to sound off about the challenges and opportunities in the skilled nursing space in an anonymous way — or know someone who might? Drop editor Alex Spanko a line and we’ll consider your submission for an upcoming Confessions piece.


Tell me about your experience with the PDPM shift.

I’ve worked mainly the past 10 years in nursing homes — primarily the same nursing home, basically. But in 10 years, even though I’ve been in the same nursing home, one, two, three, four different employers have come and taken over the therapy. I think that seems to be common with with therapy departments —they lose contracts with national companies, or they go in-house, and it just switches around.

There’s always changes with Medicare; over the past 10 years, there’s been Medicare changes, but it’s been sort of a gradual decline. We haven’t had a pay raise since 2011.


The company has changed, like I said, four different times. So there’s been a deterioration — you’re not going to get a raise, but we still want you to do more. And then there’s obviously been some big changes — PDPM, and there’s probably more to come.

People have been laid off as the companies changed. People have lost their jobs — like a few here, and then a few in the next round of changes, and then I lost my job with PDPM.

How many other people lost their jobs, or had their status change?

I think it was just me this time. When we changed, some people left on their own, and with PDPM, we had one person elect to leave because PDPM also coincided with the change of company again. It was kind of: Two things happened at the same time. This all happened the beginning of October.

Was it right on October 1?

I think I was told the end of October.

Our department is probably maybe 20 of us, with PT, OT, speech.

Walk me through how your bosses conducted the PDPM transition from your perspective — over the last 18 months, a lot of leaders told me about their plans for the change, but what did it functionally look like on the ground?

From my perspective, we started 2019 with the big national company, and they were preparing us with webinars, and then they’d do teleconferences. [It was] mandatory — everyone would sit around the phone and listen on about what changes they were going to make.

But then, in the springtime, that’s when we went in-house. And once we went in-house, they didn’t prepare us. They just didn’t have any in-services for us, or tell us anything about it. And then I guess it was around October when we were no longer in-house; another company took us over, a smaller company. At that point, they just told us to do group.

And then they also said to do concurrent. This has been the main push, that you have to do groups, and they want you to do concurrent. We used to do that 10 years ago — we were doing that, and then we were told not to do it, and now we’re being told to do it again.

What sort of justification is being given for these shifts? In theory, PDPM is supposed to allow therapists to tailor their services more closely to residents’ needs, but I have heard anecdotal stories about therapists being told to hit certain thresholds.

It seems to be that we just need to do it and we’re not told why. Ten years ago, we did groups because we just had a lot of patients. We didn’t have a lot of therapists, and I suppose it was an economic factor.

We do groups in rehab, because the focus is more that it’s socialization, and you’re going to have a topic, and it’s very well planned — whereas skilled nursing has always been difficult. You can’t always schedule your day; it’s hard to schedule a group sometimes, because people don’t want to do it all, you know, at 11 o’clock. They’re not ready.

It’s just now we don’t have as much time to schedule our patients as you do in acute rehab.

From your standpoint, do you think PDPM will achieve the goals that the government has laid out for it? For me, it’s hard to reconcile the two main opposing forces: the government saying the old system encouraged fraud, and the many therapists reaching out to me saying the new system is just making it worse in different ways.

I agree that the RUG system was just taking minutes. Fortunately, the facility I’ve been in the past 10 years, we didn’t keep people 100 days just to keep them. I mean, there was pressure, if it was the last day of their ARD and they couldn’t get their minutes, you might be asked to go back because they would lose out on money that they’d been working on for weeks up until that point. There was pressure like that.

But PDPM should be a good thing because they’re running out of money, and we don’t want to be giving services [that people don’t need]. And I know there are nursing homes that just keep people 100 days and give them lots of minutes of therapy when it’s not appropriate.

So I think it’s a good thing, but my concern is that because the money is running out, it’s our problem. It becomes our professional problem, because I think nurses are getting raises — and they’re working within the Medicare system. And the CNA is getting a raise. But because therapy is not making money, we get directly affected in our salary. There’s less emphasis on in-servicing about patient care, and more in-servicing about which code to use — and telling us that we need to do more of the administrative [work].

We don’t have a rehab tech, so we have to scan our documents and do all this extra [work] because they don’t have money, I guess, to pay for a tech to help us to transport or to do these things. We used to have a tech — 10 years ago, we had two of them.

So yeah, I think PDPM is good, but it’s bad how the companies are reacting — and they just take everything out on us. I don’t think they’ve had a pay cut, whoever is the director of the companies, or the director of the nursing home; they’re getting a cost-of-living increase, or they’re probably getting a raise, but we’re not.

It’s all the small little things that make you feel like you just are being erased, and you’re not valuable to them because you’re not making money anymore.

In the wake of the change, there’s been a sort of feeling that layoffs were inevitable, or that companies should have cut even more jobs just based on the math — but even more so than in other industries, you are dealing with people’s lives.

I’ve worked in health care enough to know that you have to change. They’re always changing their focus in rehab to where the money might be.

Twenty years ago, I was in acute rehab, and they all of a sudden started a vent unit because I think it was going to be something they could get money from. The focus wasn’t: “Oh, we have a lot of people on ventilators that need to be weaned.”

Maybe I’m cynical, but it has to be driven by: “Can we make money off this type of care?”

Is there anything else that you want leaders in the space to understand about your experience and the state of therapy today?

Residents and family are seemingly unaware of the changes. They don’t seem to know that they’re in a group because there’s been changes to Medicare and their length of stay is going to be shorter.

If the executives have any plans of educating Medicare recipients and family so they don’t expect their mom to get, you know, an hour of therapy — they might get 30 minutes — not to make big promises anymore about therapy, because we’re stretched too thin.