Nursing Homes Proceed Cautiously on Group Therapy — But Vaccinations Allow Small Steps Forward

When the Medicare payment system for skilled nursing facilities was overhauled in 2019, one of the most anticipated provisions was the option to provide therapy to residents in group or concurrent settings — allowing for more socialization and cost savings.

That provision got about four months of practice before the COVID-19 pandemic swept the world in the late winter and early spring of 2020, and the provision of therapy in SNFs was caught up in the maelstrom. As admissions to SNFs plummeted amid the suspension of elective surgeries and declines in hospitalizations, therapy providers were forced to make cuts to their workforce.

And with communal activities of any nature banned in a bid to slow the spread of COVID-19, therapists made the switch to providing therapy one-on-one — when they were allowed in SNFs at all.

But with vaccinations growing by the day and new visitation rules that require SNFs to open the doors for indoor visits with residents in most cases, some slight changes are happening in the world of therapy. For one thing, occupancy is incrementally rising as COVID cases decline in nursing facilities — and group and concurrent therapy could start to make a comeback.

“We’re seeing census increase; we’re seeing volumes increase in patients on caseload,” Susan Krall, the chief strategy officer at Quality Rehab Management — a Dallas-based in-house rehabilitation management company — told Skilled Nursing News. “I was speaking with some therapists this week and some managers of ours that have really seen group and concurrent get going again. It’s coming back — in limited fashion, but it’s coming back.”

Gyms slowly reopen – in some places

That said, it is still quite limited. For the Plano, Texas-based Reliant Rehabilitation, which has a presence in more than 870 SNFs in 40 states, group and concurrent therapy is below 3% of all the therapy provided, chief operating officer Peggy Gourgues told SNN. That’s because even in locations that allow a therapy gym to be open, large groups cannot be used.

“It’s been state-specific and client-specific as well,” she explained. “Obviously in buildings where there is no active COVID, we are reopening gyms, or clients are. It really is up to the client.”

That has also been Aegis Therapies’ experience. The Frisco, Texas-based contract therapy provider is seeing conditions vary considerably by market and facility comfort level. COVID-19 case counts in different states, or even in different regions within states, and interpretation of state and federal guidelines is another factor, Aegis chief clinical officer Mark Besch said.

While Aegis is relying on guidance from the Centers for Disease Control and Prevention (CDC) with regard to questions such as therapist exposure to COVID, for example, customers sometimes use different guidelines, and Aegis defers to the clients — which in turn shape the provision of therapy. This means that Aegis has no one answer for how therapy is provided and how it’s changing in the wake of the vaccine clinics that rolled out in SNFs starting in December of last year.

But Aegis CEO Martha Schram noted that as months have gone by since the vaccines became available, the provision of therapy is “incrementally changing,” albeit dictated by how delivery is organized under those local and facility guidelines.

Besch agreed, noting that more therapy is steadily being delivered in gyms.

“It’s probably not 100% of therapy in any single location, but definitely in the aggregate, I would say that the gyms are beginning to open up,” he said. “We’re definitely seeing a slow build of the utilization of group and concurrent therapy, [though] still quite low. But creeping up from zero, which is where it was for nine months, and rightly so. But again — not in every location.”

Some of the considerations, in addition to state and facility guidance, revolve around physical plant constraints; the size of the gym is a significant factor, according to Gourgues. For instance, if two different therapists have brought two different patients to the gym for rehab, there needs to be enough space to keep them six feet apart.

“To reopen the gym means you have to have the equipment with six square feet all around, separated,” Amy Phipps, Reliant’s chief clinical and compliance officer, explained. “Making sure that we had screenings at the door, making sure that the equipment is cleaned properly — all of those things are part of our protocol to be able to maintain the infection control while opening the gym.”

Reliant’s guidance for safely reopening gyms includes the need to ensure there are enough supplies for each resident there; no equipment can be shared over the course of therapy, and any equipment used has to be disinfected before and after each activity. And only residents not in isolation or confirmed or suspected to have COVID-19 can be allowed to attend gym therapy under Reliant’s guidance.

Those equipment restrictions mean even simple tasks like passing items back and forth are out of the question, Besch said, which entails recalibrating any therapy around those restrictions. He encouraged providers to think about what they can do, such as elastic tubing for resistance exercises with equipment for each resident, or exercises in small groups that don’t require equipment.

“Think of trying to break down that broad category of group therapy into: What makes sense?” he said. “Where does it make sense to try to do that? And how do you ensure safety? Making sure you’re only selecting patients who can wear a mask for the entire duration.”

Change in the air

Even though the move back to group and concurrent therapy is still quite limited, Quality Rehab Management — which is in more than 360 locations in 27 states — has been seeing a shift take place over the month of March, which makes Krall believe that it is likely tied to the effect of vaccinations against COVID-19.

A Centers for Medicare & Medicaid Services (CMS) database that tracks the capture of conditions under the new Patient-Driven Payment Model (PDPM) consists of findings that are five months old — but even within that dataset, Quality Rehab Management is starting to see a shift out of the Extensive Services 1 (ES1) case mix category.

That category includes isolation, and to Krall, this shift — which started to become apparent more recently — suggests a decrease in the volume of COVID-19 cases. In addition, as more people go into elective surgeries, SNFs are seeing census improve; Krall cited a client in Texas that now has occupancy higher than pre-COVID levels because of that surgery increase.

“We’re clearly seeing in the data that the isolation is coming down, which to me is a reflection of COVID leaving the building,” she said.

But she is also seeing the effects of local guidance on the provision of therapy, and Quality Rehab Management is working closely with its partners on how they’re reintroducing any form of group activity and where therapy might fit into that spectrum.

Some practices from the pandemic will continue to last. For one thing, as Krall noted, infection issues will likely happen again, even if they are not on the level of the COVID-19 pandemic, making good infection control practices paramount and ensuring that they will be a part of therapy in the foreseeable future.

“What we learned was: How do we continue to mitigate risk but still provide therapeutic intervention for patients?” she said. “If they’re not leaving the room, you don’t want to co-mingle a therapist between different hallways. We were able to become very savvy utilizing remote therapy.”

While Krall does not see this as a replacement for traditional in-person interventions, it is a solution useful for therapists to have in their toolbox for infection control, she said.

For Aegis, whatever the new normal for skilled nursing and therapy becomes, it will not be like “the old normal,” Besch said. Therapists will always have to be thinking about the ability of residents to mask, be aware of sharing of supplies and cleaning of surfaces, and the degree of proximity for patients, he posited.

But there have been some lessons learned about how to provide the best therapy for patients during the pandemic, he noted — lessons that therapists should keep in mind even after the restrictions of the pandemic have been lifted.

“In-room therapy, while it was mandated and felt burdensome, therapists will tell us there’s been blessings to that, because it’s so functional,” he said. “We’re not having a patient practicing getting on and off a table in the gym; they’re practicing getting on and off the bed they sleep in every single night. They’re walking around their room and the obstacles in their room, instead of cones that are set up in a therapy gym to create an obstacle course.”