With the public health emergency ending, new therapy trends may take hold in the skilled nursing industry.
In particular, an increase in concurrent and group therapy holds the potential to improve patient outcomes while also shoring up margins and addressing labor pain points.
“You’re going to start seeing group and concurrent therapy again,” Rick Matros, CEO of Sabra Health Care REIT (Nasdaq: SBRA), told Skilled Nursing News, as part of his 2023 outlook.
The rise in concurrent and group therapy would mean that services can be provided more efficiently from a labor standpoint, which would help margins as well, Matros said.
Concurrent therapy is different from group therapy in that it typically involves one therapist working with two patients who are doing different activities, such as physical therapy treatments. Group therapy involves one therapist working with up to six patients who are all doing the same activities.
Both these formats are becoming a more viable option for therapy at skilled nursing facilities as infection control measures ease. However, they may not become the ubiquitous form of treatment for the industry anytime soon because of time limits over deploying simultaneous therapy for multiple residents. This, despite social and financial benefits associated with group or concurrent therapy, although these formats may not be that well suited for higher acuity patients.
“There’s a rule for both group and concurrent, it can be no more than 25% of the therapy received for any patient by a specific discipline,” JoLynn Munro, president at Infinity Rehab, a contract rehabilitation provider which works with nursing homes, said. “So, it’s a very limited amount of time that either of those modalities concurrent or group can be delivered to individual patients.”
Munro said that the Patient Driven Payment Model (PDPM) has helped alleviate some of the administrative burden of planning group and concurrent therapy from the Resource Utilization Groups (RUGS) model.
“One of the provisions of PDPM was that they would allow a certain amount of therapy to be delivered with modalities,” Munro said. “As an occupational therapist, I always thought that was such a tremendous benefit to my patients.”
Still, due to infection control concerns and planning limitations, the percentage of facilities Infinity Rehab works with in these modalities is below 10%, far less than the CMS limitation of 25%.
Still, the benefits are worth examining, she said.
“We know from our own work that one way to do group therapy is through circuit training,” she said. “And it’s in the research that it’s such a highly effective model for providing high intensity training for older adults.”
Improvement in patient engagement
She said that in skilled nursing, high intensity training helps to build patients’ physiological capacity to prepare them for discharge.
“Once they’re discharged, if you haven’t built that underlying capacity, we just see such a high risk of patients relapsing or being readmitted to a facility,” she said.
Munro said there are many social benefits to concurrent or group therapy for patients, many of whom were quarantined to rooms during COVID and experienced detrimental social isolation.
“It really helps people to see that they’re not the only ones who are experiencing these health challenges and helps to build that social support structure, which is very effective in modeling,” she said. “So when we do group therapy with our patients, one of the things that we see routinely is that our patients do better in a group setting because they’re cheering one another on or there’s that little bit of competitive environment that really can enhance patient engagement.”
From a care delivery perspective, Dr. Azlan Tariq, chief clinical officer of Medrina, said that concurrent therapy can be beneficial when patients are paired with other patients who have similar levels of medical complexity.
“For example, a stroke and a dementia patient,” he said. “Dementia patients tend to look at other people and copy, so [concurrent therapy] can be much easier for them. Sometimes, it can be more challenging when they are disruptive, but typically dementia patients in the group tend to do better.”
Impact on revenue models
Munro said that both concurrent and group therapy can be a cost effective solution for providers who are experiencing staffing shortages.
“This is a really efficient way to deliver high quality care,” she said. “So, it helps us use scarce labor resources and also provide a high quality treatment approach for our patients.”
Since in group therapy, a therapy assistant can work with patients while a physiotherapist oversees the treatment, operators can bill for two patients at once.
“Now you have to add a modifier for concurrent therapy, so you’re not getting paid the same amount as for individual therapy,” Dr. Tariq said. “But at the same time now you can see two patients in 30 minutes … Overall if you reduce the overhead and the staffing issues, obviously you’re saving money there.”
Yet despite benefits, Cynthia Morton, executive vice president of Advion, said she does not see concurrent and group therapy increasing in Advion’s national data. Advion is an association that represents therapists working in skilled nursing facilities.
“Concurrent and group therapy are not easy to set up, the therapist has to organize several patients to be ready for therapy at the same time,” she said. “With the labor shortage and some patients just not always ready for therapy, it can be hard to make it happen.”
Morton said that although the therapist shortage is dire and labor costs continue to rise, she wants to make sure that therapy fits patients needs.
“If we could find cost savings somewhere it would be very helpful, but concurrent and group therapy have to be clinically appropriate — this is very important,” she said.
Impact of rising acuity
Skilled nursing facilities are seeing a rise in patient acuity, and for higher acuity patients, concurrent therapy may not be the best option.
Munro said she does not predict that rising acuity in skilled nursing facilities will go down anytime soon, particularly because there is a movement for more patients with less severe conditions to receive at-home care.
“We see far fewer of those patients and we see many more of their very vulnerable patients who have significant restrictions in their activity tolerance or medical complexity,” she said. “Pre-pandemic, about 20% of our patients were in that kind of category of patients. And today it’s right about 35% of our patients.”
Although those patients do make gains in concurrent therapy and stabilize, they need much higher levels of care and are still very vulnerable for hospital readmissions.
“Sometimes with high acuity patients you may not be able to put them together for group and concurrent, ” she said.
Still, Dr. Tariq said that with some leadership, even groups of patients with higher acuity could potentially benefit from concurrent or group therapy.
“It will take some fine tuning to figure out, ‘Okay, out of this group of patients that I have, these two or three would potentially benefit from concurrent therapy because they do similar things,” he said. “They might be doing occupational therapy with a similar type of equipment or similar things that one therapist can keep an eye on.”
He said that he thinks that concurrent therapy will make a gradual return.
“It’s just going to be slow because in the last couple of years, people have gotten used to one-on-one,” he said.
