Therapy in nursing homes has been shaped in recent years by the shift to a patient-centered model, with providers pointing to staff shortages, reimbursement changes, and the influence of Medicare Advantage plans as factors making it harder to tailor programs.

Certainly, higher expectations from therapy-based clinical outcomes is changing the therapy market landscape, said Brian Plasky, chief clinical integration and reimbursement officer for Genesis Healthcare. And, the change is in part being driven by referral sources and payer plans like Medicare Advantage (MA). Instead of a therapist with a clinical background determining what a patient needs, care is being “dictated” by MA plans in particular, he said.

Moreover, communication between nursing homes and therapy services, which was never seamless, is even more challenging now with rising acuity and focus on clinical outcomes, leaving widening gaps that need to be filled by an improved integration of teams within the nursing home. Also, some operators are turning to external solutions such as a greater use of physiatry groups. 

“We’re still delivering the clinical care, getting the desired clinical outcomes, but the rules are different for every [managed care] payer or referral source that a patient is attached to,” Plasky said, referring to the added burden from MA plans in the aftermath of a move away from the RUGS system. “You have a shift not only on a diagnosis of a common patient group, but more so that diagnosis and who is paying the bill [has changed].”

The shift from RUGS to the Patient-Driven Payment Model (PDPM) places more of an emphasis on nursing and less on therapy services. In other words, RUGS had more of an emphasis on therapy minutes and PDPM is more about clinical outcomes.

Asim Aziz, COO for physiatry group, Comprehensive Rehab Consultants (CRC), echoed Plasky’s thoughts on how changing reimbursement streams are affecting therapy services in the nursing home sector.

Physiatry groups such CRC are able to bridge the communication gap between nursing homes and therapy services, providing an extra layer of clinical support especially around orthopedics, neurology and pain management, all of which are closely linked to therapy services, Aziz said. 

Genesis, meanwhile, has a therapy services subsidiary, Powerback Rehab; Plasky previously served as senior vice president of operators for Powerback, with 25 years of experience in therapy services.

All in all, who dictates clinical care is shifting the relationship dynamics between nursing home operators and therapy providers, with operators increasingly considering how to integrate therapy services into interdisciplinary teams moving forward, said Plasky.

This integration makes sense, especially considering a heightened focus on admissions and discharge processes tied to survey changes due to be implemented at the end of the month, as well as Medicare Advantage plans’ focus on a shortened length of stay.

“It’s not only the scope of the therapy practice that we have to look at anymore,” said Plasky. “How does what we do as therapists fit into the nursing plan of care, or the physician plan of care? What do they need when they leave? Who’s going to be there to take care of them, and how well did we prepare the caregivers?”

A shifting nursing home-therapy provider relationship

Leverage now lives almost entirely with nursing home operators when it comes to the operator-therapy provider relationship, Aziz added. More nursing home operators in the sector, and new models for therapy services are emerging, that give facility owners more flexibility to go in-house with therapy services.

And so, customer service and accountability have become top of mind for therapy partners, because they know operators have a variety of options for therapy services, said Aziz.

“If facilities are not seeing the outcomes that they want for the patients or the collaboration that they’re looking for, there will be 10 more companies lining up to take on that role in the [nursing home],” said Aziz.

Providers left in the dust will be those that can’t break out of their silos, Plasky said. That goes for therapy providers and nursing home operators alike.

“Those that are going to succeed are learning to work better together, and not lose sight that the number one goal is the clinical outcome for that patient,” said Plasky. “We have to be involved just as much inside the building as outside to be able to follow that patient until they’re completely through their course of medical care for whatever brought them in to begin with.”

Rising acuity poses unique challenges to communication, collaboration and consistency between nursing homes and therapy providers, but physiatry groups often bridge the gap between therapy providers and nursing homes, said Samantha Tilton, clinical services team lead for CRC.

“With increasing acuity in the building, it gets harder to kind of keep your hand on every single button,” said Tilton. “That’s a challenge for the therapy team, of bridging a gap between everything else that goes on in the building, including the billing aspect, the post discharge aspect, working with nursing, working with primary care teams that, depending on the facility, may be very present or may not be.”

Supply and demand, and telehealth

Plasky said there’s also a troubling trend of less supply and more demand for therapists – and operators need to fight harder to attract therapy specialists to the space. It’s a trend the skilled nursing sector has seen with other clinical positions.

“One of our biggest concerns is the ability to recruit and retain therapists,” said Plasky. “Therapists are becoming very innovative and entrepreneurial in where they can be employed. Twenty years ago, they had essentially four different places to go to work. [Now,] it’s 20 different places they can go to work with all the little niche markets within the confines of therapy as a whole.”

Skilled nursing operators can’t move their clinical services forward without therapy services as part of the team, and they’re in a constant battle to ensure such specialists are brought on and kept on long-term, Plasky said.

To that end, telehealth offers some relief.

Telehealth for therapy services in nursing homes is “hanging over” the sector, Plasky said, with the ability to provide such services virtually getting an extension prior to a final decision from the federal government. 

“Telehealth was something that certainly came about during the pandemic, but it actually proved to be a very valuable piece to the medical landscape as a whole, both for physicians and therapists,” said Plasky. “We’ve been able to prove that it’s filling a void that has always been there and was just never explored.”

Plasky hopes policy makers will find that telehealth therapy services are indeed worth continuing.

And sharing clinical outcomes through tech platforms is another addition Plasky hopes will stick around, especially when it comes to clinical outcomes for nursing home residents that are driven by therapy services.

“In the past, nursing homes had a set of outcomes, and therapy had a set of outcomes. Physicians had a set of outcomes. We’re really excited about looking more at patient outcome [overall], and then how those various interdisciplinary teams contribute to a common outcome per patient,” said Plasky.