The world of third-party rehabilitation was braced for a change in the skilled nursing setting when the Patient-Driven Payment Model, the Medicare reimbursement overhaul that took effect last year, effectively removed therapy as the driver of payment.
A few months into that new landscape, the world itself was upended by a global pandemic — one that had a unique effect on the operations of SNFs, adding another twist to the path third-party rehab providers must navigate.
For Tammy Tuminaro, the recently appointed CEO of the Baton Rouge, La.-based Century Rehabilitation, the changes are the latest in a long line of upheavals to rehab in the SNF setting, and she’s charting the course for Century accordingly after serving with the company in a variety of roles for 17 years.
Tuminaro joined Rethink last month to talk about the evolving role of third-party rehabilitation in SNFs, and how Century is getting ready to forge ahead in a health care landscape driven by outcomes and shaped by a pandemic.
When COVID-19 hit, what did Century Rehabilitation see in terms of changes, and how did you respond in working with your SNF partners?
With COVID-19, what we’re finding as a company is that we are constantly having to re-evaluate our service delivery model. Overall, our goals have not changed: Our residents still need care, we are committed to providing quality care with the best outcomes. However, our approach has had to change slightly.
With the implementation of telehealth, that was really — I don’t want to say necessary evil, but while it’s not the ideal mode of delivery, in our opinion, it’s definitely needed. We’ve lost some of our efficiencies as well. But like I said, the residents still need care and even more so now, what we’re finding is that [for] some of our residents, the needs have changed. We’re seeing because of a lack of socialization, maybe more cognitive deficits, more depression issues.
The other thing that we’re really finding, and it’s just now starting to emerge, is what are the long-term effects of COVID-19 on patients in skilled nursing settings, some of the respiratory issues that we’re starting to see.
And then [there’s] what’s yet to be seen, but I think, primarily our focus has not changed. We’re still looking at the best way to give quality care with the best outcomes and to work with our partners. Infection control, of course, has been a big topic, and we’ve had to reevaluate how we go about our day-to-day with our therapists. That has never really been an area where therapy was really concerned with PPE [personal protective equipment] and those types of things.
We are re-evaluating it every day, but our goals never change. We are committed to giving the best quality care and the best outcomes for the residents.
Can you talk a bit about some of the challenges you ran into with telehealth? Overall, there’s a lot of optimism about what it means for care in the SNF setting, but with therapy, it sounds like it might not necessarily be the most optimal mode of delivery?
Telehealth for therapy developed out of a need, a necessity, and I do think it has a place and it’s a great option when there is no other option. We definitely believe face-to-face interaction is best.
But ultimately our patients need care, and we have to become creative and resourceful to ensure that care and the outcomes. The biggest challenge has probably been just re-educating therapists on when and where this is applicable, as well as having hands-on resources in the facilities from the technology side. So sometimes it’s a challenge because of just manpower; while we can remotely have a physical therapist or an occupational therapist dialing in, we still have to have someone on the ground, in the facility with the resident.
And from a technology standpoint, sometimes the population that we’re dealing with is not as technologically savvy as some other populations. So that’s been one of the biggest challenges, just re-educating to use the technology and having the boots on the ground in the facility to be able to facilitate the telehealth.
How has Century handled that element of needing boots on the ground in facility, and how do you foresee handling it, given that the current situation is likely to be around for a while?
We have a presence in every facility, first and foremost. We have gone out and we have beefed up our staff.
In the past, we may have had a physical therapist that did evaluations in two, maybe even three facilities, if they were near each other and with smaller census. Now, we can’t have those folks present in all three of those different facilities. So we’re doing telehealth from that aspect. But we have not taken our assistants, or maybe rehab tech [out of the facilities] — somebody is still in that facility.
In many cases, it meant we had to go out there and hire more staff, which I think for in this environment is a really good thing. We saw so many therapists get furloughed, or clinics just had to shut down for some time. But in the skilled nursing setting, we couldn’t shut down; we had to be there, and rather than cutting our staff, we started adding to our staff and trying to become more efficient.
We also have worked very closely with our partners in the facility. So the operators in the facility — in some instances where it may have been a little bit more difficult for us to have somebody in the facility for six to eight hours a day readily available — we have partnered with the operators to determine: Do they have staff, perhaps, that could help us in this situation, Whether it be may be a restorative aide or a CNA [certified nursing assistant]? We’ve been very successful in that area as well.
Again, our goals are the same; our goals are aligning. The residents still need the care, and we’ve still got to work toward those outcomes.
That point about is something I wanted to ask about: How have you seen the relationship between SNFs and rehab providers change over time, and where do you see that going as more and more providers zero in on outcomes?
I almost want to say: “What has not changed?” rather than what has changed over the years. But I think for Century, what has not changed is that we have always been in the business of building really strong partnerships — not just being a vendor, but going out there and really building a partnership with our operators to ensure that quality care and excellent outcomes.
In the past, rehab or therapy was more of a department within a nursing facility, and now we are much more integrated. In the past therapy came in, we may have told the facility what we were doing, maybe gave an update on progress with the resident, but pretty much just came in and told them what we were doing and moved on.
Now it’s a true collaboration with the entire interdisciplinary team. We are constantly re-evaluating what we’re doing, and how it fits in with our clients’ goals. I think for the future, flexibility will be the key. Historically, contract therapy providers in the long-term care setting have had a certain way that they set up their program. I think going forward, we will have to have flexibility with our service models, whether that’s having value-adds, new service lines, maybe different models of care delivery.
Whatever it is, we’ve got to do whatever we need to do to achieve those outcomes, and align our goals with those of the facility.
So what does that look like for Century, and how are you thinking about it as you go into this new role?
We have always focused on outcomes. So what we think that looks like going forward: We are implementing some different strategies from some of our auditing tools where we’re looking at outcomes versus maybe documentation strengths.
In other words, we’re trying to correlate: Residents with really good outcomes, does that correlate to therapists who have very good, strong documentation skills? And what we’re finding is that there is often a correlation there.
So we start with looking at the competencies of our therapists — and when I say competencies, it’s not to go out there and find who’s not doing something the right way, but more identifying trends and opportunities — and using that to educate and give our folks the resources that they need to do their job, whether it be better clinical pathways, decision trees, whatever we can give our folks to make them more efficient and focus their care on treating the resident.
Also with outcomes, there’s so much data out there, and we have a lot of unused data. We’re actually working with some outside partners to take some of the data we already have — because we collect it, CMS is collecting it — and really be able to tap into that through some of the data analytics tools out there, to really be able to extrapolate and show our partners what we truly are doing and what our combined efforts are accomplishing.
We recognize that we’re going to have to partner with some folks outside of our expertise to really get down to that, and be able to to show our partners — as well as to show the entire industry — that what therapy does within the nursing facility really does have value, at the end of the day.