How Therapy Providers Can Drive SNF Upside and Optimize Reimbursement

Therapy providers in the nursing home space believe their role in increasing mobility will contribute to upside in the sector – especially within the context of the Patient-Driven Payment Model (PDPM), pandemic recovery and staffing challenges.

It’s a draw for prospective residents and their families, both on the short-term and long-term side, as clinical improvements range from reduced falls and hospitalizations to increased cognition among therapy recipients, according to Cynthia Morton, executive vice president of Advion, the lobbying group formerly known as the National Association for the Support of Long Term Care (NASL).

“Therapy is the engine to get these patients ready to go home, if they’re going home, or it can be the engine that really helps them become more independent,” Morton said of both the short stay and long-term care resident.


Morton spoke virtually at Skilled Nursing News’ Therapy Summit last week along with Scott Wilson, president and CEO of Elevate Therapy Consulting Group and Shaun Smith, president of integrated care services at Asbury Communities.

“Therapists represent a highly educated and trained portion of your care team. Often your [occupational therapist (OT)] or your [physical therapist (PT)] has a doctorate level education – they’re key to maintaining or improving [the] function of your patients and your residents,” added Morton.

Another upside, according to Smith, ties into that expertise. Therapists can provide education and training opportunities to those on the nursing side and help transition residents once they’re ready to leave the skilled nursing facility.


They also help fill the gaps in direct care, Minimum Data Set (MDS) logging and onboarding.

“I’ve seen firsthand in some of my facilities a lot of creativity with in-house models. I’ve got a facility where the OT coordinates the [Restorative Nursing Assistant (RNA)] program. There’s a PT that does admissions … a speech therapist that helps drive the MDS process,” Wilson said. “They’re clinically competent folks who can go out and really help with that.”

There’s a bit of nuance there too, he said, as therapy providers are careful not to “step on any [nursing] toes” while also helping alleviate the staffing crisis by dipping into roles not usually reserved for them.

“Therapists are smart individuals. They can educate, they can teach, they can train, and there’s a lot of opportunities for them in a SNF setting,” he added.

Holistic therapists and PDPM

With the introduction of PDPM in 2019 therapy providers have had to dramatically shift how they think about program development as it’s more prescriptive and patient-centered rather than by the minute, a relic of the Resource Utilization Group, Version IV (RUG-IV), according to Morton.

Prior to PDPM, reimbursement for therapy services was calculated by how many minutes the service was provided.

“We were so hooked on minutes for such a long time, we’re starting to see less focus on just minute criteria, and more what does that patient need,” added Wilson.

The shift in payment methodology means SNF providers will need to pay closer attention to coding, he said, identifying comorbidities and correctly scoring international classification of diseases (ICD-10), among others.

“I think there are several checks and balances in place that need to be occurring to make sure you’re scoring an MDS appropriately to get the reimbursement to take care of those patients,” Wilson added.

A lot of it goes back to staffing challenges in the nursing home setting, he said, with those at the facility level not accurately scoring MDS to get the appropriate amount of reimbursement.

Coupled with PDPM are outcome measures included in the five-star rating system tied to rehospitalizations and staffing data. More outcome measures are coming, Morton warned; CMS got the green light to add measures to the VBP and could potentially up the 2% withhold to 8% or 9%.

“Congress can’t wait to get their hands on that 2% withhold … our sisters in the home health sector, they’re on the hook for up to 10% withhold in their value-based purchasing program,” added Morton.

Morton “really can’t say enough” about what therapy can do to directly improve outcomes and in turn maintain current reimbursement.

“If we move into more advanced types of value-based purchasing programs, and I’m just talking fee-for-service, there’s many other programs on the accountable care side that will only expand as CMS moves forward with their goal of having all patients in Medicare under accountable care programs by 2030,” added Morton.

Mobility upside and the staffing crisis

If residents gain improved mobility through patient-centered therapy programs, there could be a long-term positive impact on staffing, the panelists said. More mobility means less staff needed to get a resident out of bed or help with daily living activities.

“In the long-term care side of a building, if you can get those patients to be more independent and to do more for themselves, that’s reducing a lot of burden on staff that can be freed up for the [Medicare Advantage (MA)] patient, really help increase the quality of life, or improve what’s going on in that building,” said Morton. “It certainly can help with a staffing shortage and can save a little bit of money for the facility if they have to rely less on staffing.”

A more short-term impact includes therapists being able to help with areas of nursing that are appropriate such as education and helping the activity coordinator, added Smith. In other words, in-house OTs and PTs especially can help other direct care workers get through their day.

If SNF providers are willing to be flexible and creative, there are a lot of ways therapists can be further incorporated into operations, Wilson added.

“I saw a lot of great examples during Covid, where contract therapy providers were working directly with providers, operators to help with the staffing crunch,” he said. “There are opportunities there to be had – you just have to have those conversations.”

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