Increased intensity of therapy services may directly lead to better outcomes for residents in nursing homes and other post-acute care settings, according to a new study backed by a pair of trade groups that represent physical and occupational therapists.
Skilled nursing facility residents who received high-intensity therapy — defined as about 90 to 219 hours across all conditions — had the lowest rates of 30-day hospital readmissions, the American Occupational Therapy Association (AOTA) and the American Physical Therapy Association (APTA) found in a new data analysis published Monday.
The effect was less linear for changes in functional status, another key indicator of quality post-acute care, with the biggest gains in functional status coming for people in the “typical-intensity group” — defined as about 22 to 27 hours on average.
For example, patients who received typical therapy had an average change in functional score of 3.52, compared with 1.83 for the low-intensity cohort and 3.29 for the high-intensity group. The general pattern was the same for those receiving post-acute care for strokes and joint replacement surgeries, with the improvement peaking in the middle and declining slightly for those in the highest-intensity therapy groups.
APTA and AOTA commissioned consulting firm Dobson DaVanzo & Associates to perform the analysis, which drew on Centers for Medicare & Medicaid Services (CMS) data from 2015 and 2016. The dataset included 639,000 skilled nursing stays, along with 197,000 stays at inpatient rehabilitation facilities (IRFs) and 552,000 home health episodes.
“The study provides clear evidence that physical therapy and occupational therapy services improve patient outcomes across all PAC settings,” the groups concluded. “Findings consistently indicate that these services are associated with greater increases in function, suggesting a high potential for harm to patients who receive the fewest minutes of therapy.”
APTA and AOTA also used the data to warn policymakers against adopting a site-neutral payment model for post-acute care, a long-standing goal of some payment reformers who question why Medicare and Medicaid incentivize institutional care over the home health setting; such discourse will likely only increase given the waves of death seen in nursing homes during the COVID-19 pandemic.
“Policymakers should not assume that there is clear overlap among the PAC settings for treating similar patients, as patients in each setting have different treatment goals and are at different points in their recovery,” the groups observed. “These findings also indicate that CMS should monitor the level of therapy provided in PAC settings as payment incentives change in order to help protect patient access to medically necessary skilled therapy, especially patients with high rehabilitation needs.”
The data predates the most recent seismic shift in the way Medicare pays for therapy services in nursing homes: the Patient-Driven Payment Model (PDPM), which took effect at the beginning of October 2019.
CMS explicitly framed the shift to PDPM as a way to crack down on fraudulent therapy practices. Under the old Resource Utilization Group (RUG) model, a higher volume of therapy minutes directly generated more revenue for nursing home operators — leading to several high-profile False Claims Act cases in which providers were forced to repay millions to settle allegations of providing unnecessary therapy services driven by profit motives and not resident need.
But after the transition to PDPM, the incentives reversed essentially overnight; once a building’s primary revenue generator, therapy instantly became another cost for nursing home operators to manage in the complex world of Medicare and Medicaid reimbursements. Therapy groups and individual therapists sounded alarms about the pendulum swinging too far in the other direction, with a near-immediate round of layoffs raising concerns about nursing home residents not receiving enough therapy.
Just a few months into the new system, the COVID-19 pandemic torpedoed the cost-saving strategies that providers had talked up during the months preceding the PDPM transition, including increased use of group and concurrent therapy services — which were rendered impossible amid a blanket ban on activities in communal spaces.
Though vaccination efforts have cracked open the door for group sessions to resume, the long-term effects of the pandemic and PDPM on therapy in SNFs remains unclear. PT and OT staff levels dropped up to 10% in the wake of PDPM, a recent study found, with most of the cuts coming from third-party contract firms; the ongoing preference for home care given the coronavirus death toll in nursing homes has also prompted providers to cut staff and rethink their therapy strategies.