Fit residents at lower cost.

Limited reimbursement for P/OT evokes creative answers

SINCE THE IMPLEMENTATION OF THE PROSPECTIVE PAYMENT system (PPS) by the Health Care Financing Administration (HCFA), physical and occupational therapy have been under cost-reduction pressures in long term care. But although the hours for therapy are more stringently allotted, some therapy practitioners and facility administration have managed to keep resident care from falling through the cracks. They have learned to make resources meet the needs of those who require therapeutic help, and prudent use of therapists' time has been the key.

At Brandywine Senior Care, Exton, Pa., "We decided to bring therapy in-house because of the change in reimbursement," says vice president of clinical operations, Susan Klein. "The high cost of contracting for physical and occupational therapy made having our own staff more economical. Now we don't worry about time spent at team meetings and other internal functions. In contract arrangements, you pay for every minute the therapists are on site."

Brandywine, which operates 14 nursing homes and 6 assisted living residences, does contract, however, for a consultant's oversight of physical and occupational therapy--because the facility wants to be at the cutting edge in its practices. "These therapies change rapidly," Klein explains.

Is there a therapist in the house?

Brandywine has no trouble finding staff and no problem retaining therapists. "Therapists have priced themselves out of the game because of the new reimbursements," Klein comments. They are now glad for in-house jobs.

In addition to aid in conserving on the bottom line, another benefit of having therapists on staff is the ability to have them offer consistent, everyday contact with the residents--even outside of scheduled therapy hours. "For instance, the therapist might go into the dining room once a week to see if anyone is having problems with food," Klein points out. "Perhaps someone isn't eating well because she can't manage the silverware, (See "Mealtimes are a big deal," January 2001 CLTC, page 18.) With a therapist coming in to proactively evaluate these issues, we don't have to wait until a resident develops real nutritional problems to step in."

Moreover, with in-house staff, the same therapist can work with a resident for each session, adds Klein. Often with contract services, different therapists come at different times, which can prevent a therapeutic relationship from developing,

Tai Chi, yoga, exercise equipment

As an independent consultant, Jennifer Bottomley, president of the geriatric section of the American Physical Therapy Association, visits nursing homes and assisted living facilities to evaluate the functional level of the residents, the available space, and the availability of physical and occupational therapists. She then designs an exercise and nutritional program for the facility.

Where Medicare reimbursement is available, programs can be made specific to the individual and one-on-one therapy is given, notes Bottomley. In other situations, where costs must be kept down or where therapy limits have been reached, Bottomley may suggest that Tai Chi or yoga be put in place as a group intervention. She likes these alternative exercise modalities because they help residents develop flexibility and balance, as well as strength.

"Falls are the biggest concern for seniors and the biggest cause of serious injuries and broken bones," she observes. "Those who are flexible can regain their balance if they are about to fall."

Bottomley, who works in the Boston area, has been participating in a large, 102-nursing-home study funded by Nautilus Human Performance Systems, the company that makes exercise machines for specific muscle groups. "In comparing seniors who work out with those who don't, we are finding that individuals who exercise do much better overall," she says. The groups using the equipment, versus those who won't, are self-selecting. "Those who are entirely disinterested become the control group," she says. (See "Beverly and Nautilus ally," page 14.)

Often, however, these non-users, too, get excited when they see the progress made by their peers who exercise. They then want to get involved.

Prevention is cheaper

Everyone entering the program is evaluated by a physical therapist and given a specific routine. If the person has trouble rising from a chair because of weakness in the thigh muscles, that individual will be encouraged to use the quad machines. Someone who is strong will be given a more generalized workout. Stretching is done both before strength exercise and after.

"The residents never get stuck in a routine, either, as they are evaluated weekly or every 14 days," Bottomley remarks.

Her preventive orientation is one of the reasons why Bottomley decided to obtain two Ph.D.s--one in gerontology and one in legislative administration and policy management. On the federal level she is now an advisor to the Office of the Surgeon General and hopes that Medicare will begin to fund preventive therapies. "Prevention is cheaper in the long run," she declares. "People have fewer falls and fewer illnesses." (For a more in-depth look at falls and prevention, please look for our cover story in next month's CLTC.)

An active lifestyle is the best prevention for many "old age" ills, Bottomley observes. She cites another study in which she is involved, at Beth Israel in Boston, that has gathered a group of 156 seniors over the age of 100 for an exercise program. All those in the study are community-dwelling and very active, performing all activities of daily living--and more. "We are seeing that those who are active throughout life are better able to maintain functional levels."

Because of federal reimbursement limitations for physical and occupational therapy and a number of provider groups closing their doors, Bottomley has found that more and more facilities have hired in-house staff. Sharing arrangements between facilities in a chain are often made, perhaps with the therapist spending a full day at each of three residences and then dividing the other two days according to which facility has the need. Still, some facilities continue to contract out their physical and occupational therapy, she states.

Less of a therapist shortage

At the Parker Jewish Institute for Health Care and Rehabilitation, a voluntary facility in New Hyde Park, N.Y., a full range of services includes a residential dementia unit of about 80 beds and two clay care programs--one for those with Alzheimer's disease and one for other seniors. In addition, Parker provides long term home health or what is known in New York state as a "nursing home without walls" to about 700 patients who, with 8 to 16 hours a day of care, can remain in the community under this Medicaid program.

Each one of these components of care offers physical and occupational therapy, explains Barry Zeman, president of the 527-bed facility. "We see less of a shortage of physical therapists since the federal government changed its reimbursement rules. Therapists are not so well-reimbursed in private practice now and they are not so much in demand," says Zeman.

Recruiting is easy for Parker Jewish, anyway, as the nursing home is a "desired employer" because the facility is large and well-staffed, with good programs, and the pay scale and benefits are attractive. "We have a consistent staff of physical and occupational therapists. Here, they get to see patients with more difficult problems than in a more static environment and can learn more, so they like being here," Zeman affirms.

The physical therapy program is planned via a team approach among physiatrist, staff geriatrician, and the physical therapist. Because the facility is located right next to Long Island Jewish Hospital, which is a teaching hospital and has a geriatric program, the institute benefits from a close association with the hospital. "We keep up to date," Zeman says.

Most of the therapists who go into the field to work in the ancillary, at-home program are per diem workers. These individuals also fill in at the facility when they are needed. Even though they are contract therapists, they are consistent staff and are known to administration and the residents.

Zeman feels that reimbursement for physical and occupational therapy will swing back to somewhat higher and fairer rates. "The federal government overdid it with the cutbacks and a lot of places had to close. I think we will see this moderate," he says.

Therapy in adult day care

Many of the small adult day care centers that consult with Adult Day Care and Assisted Living Group in Blue Bell, Pa., don't set up physical therapy programs because of the burden of required paperwork, remarks president of the group, consultant Lowell J. Spirer, M. S., a former hospital administrator. "You have to become a provider with a provider number then and the process is a little expensive for the types of places that have around 25 clients, a common size for adult day care around the country. The only time this would happen in a small facility is when the owner is a physical therapist himself," says Spirer. "Most adult day care centers will provide transportation to a hospital for physical therapy for those who need it."

In California, though, the state requires adult day care to have a physical therapist available, if not on staff. This may become a model for the rest of the country, Spirer speculates.

In some instances, an outside firm might rent space at the adult day care center to provide physical therapy in the setting.

Having physical or occupational therapy on the premises is a plus, of course, because many of those in adult day care need the help and then don't have to leave the premises. More adult day care providers are for-profit operations than previously, Spirer adds, and he sees Medicare-reimbursed rehabilitation therapies as a good profit source, generating significant sums of money each month.

Adult day care is, in part, about exercise if not physical therapy, Spirer believes. "Exercise could be considered a large part of the day care program. Older people need physical activity, but that's one thing they often decrease as they age. This generation is now living 10 years longer. You can't live a full life and then sit down and do nothing. So long as people continue to live, they have to live appropriately."

In the assisted living facilities, where he also consults, Spirer says that the original plan often did not include physical therapy. "Many facilities are now adding physical therapy staff, as assisted living competes with the nursing homes for residents who are both older and less functional."

OT reorients goals

At the American Occupational Therapy Association, Bethesda, Md., the director of practice, Maureen Freda Peterson MS., OTR/L, advises that with a decreased number of occupational therapy hours, the great emphasis be on productivity. "Therapists have to justify their existence," she says. "Schedules are no longer regular ones. An occupational therapist might work seven hours one day and five hours on the same day the following week, because of a reduced facility census." Most occupational therapists, states Peterson, still work on a contract or as-needed basis with no guaranteed hours.

"Therapists have had to be creative as to how they deliver services since the onset of PPS with less therapy--and more restrictions and guidelines based on the Resource Utilization Groups--RUGs--level," she explains.

"Although HCFA makes clear it has set forth guidelines and not limits, the institutions have tended to look at this differently," Peterson finds. "The nursing homes take these suggestions as absolute, rather than risk fighting HCFA over reimbursement."

Occupational therapy has not changed its basic objective, which is to help the patient achieve personal goals toward independent functioning, Peterson believes. "Therapists are no longer able to offer the intensity of work that they used to," she says. "They try to prioritize together with the patient, and might help with three functions rather than seven." Philosophically and conceptually the work is different, though the actual therapy with the residents remains the same.

Gail Hayden is a freelancer based in Manhattan.

Beverly and Nautilus ally in 8 SNFs

Beverly Rehabilitation, Fort Smith, Ark., and Nautilus Human Performance Systems, Independence, Va., have joined to provide strength training to elderly patients in eight Beverly skilled nursing facilities. These sites will serve as pilot centers, but, eventually, the new program, Freedom Through Functionality, may expand to more than 400 locations.

Beverly will offer the program to residents as part of their rehabilitative program, to seniors living outside the facility, and to seniors who have completed a physical therapy program in-house and who want to continue to increase their strength. Facility staff will be trained to oversee the exercise and special guidelines will address such conditions as arthritis, asthma, cardiac rehab, diabetes, hypertension, knee and shoulder problems, low-back pain, obesity, osteoporosis, and Parkinson's Disease.

A study performed at the Medical Center of the John Knox Village Campus in Orange City, Fla., a skilled nursing facility for seniors, documented improvements in mobility, strength, and functional independence measurement (FIM) in 14 women and 5 men who completed 14 weeks of strength training. The participants averaged 88.5 years old and exercised an average of twice weekly. Their strength training protocol utilized only five Nautilus machines, and the subjects performed only one set of 8 to 12 reps of each exercise, beginning at minimum resistance levels. The results showed a 14.2 percent increase in the FIM score, an 81 percent increase in lower body strength, and a 38 percent increase in upper body strength.

Other improvements included a 9.7 percent reduction in overall body fat, 3.8 pounds increase in lean weight, 9.4 percent increase in shoulder abduction range, 52.8 percent increase in seated hip flexion range, 71.4 percent increase in mobility distance, and 36.4 percent reduction in falls.

Why one LTC facility chooses to outsource its P/OT

Here's a case study claiming the benefits of contracting for rehab services

The Fountains at Canterbury, an Oklahoma City retirement community, houses a 120-bed long term care facility, a 60-bed assisted living center, and two Alzheimer care group homes. In addition, it offers an independent living environment complete with a heated pool and fitness area, 71 apartments, and eight cottages.

When The Fountains' administrators decided to outsource management of rehabilitation services in 1994, they tried a variety of rehabilitation providers. In 1999, The Fountains selected one to provide in-home assessments and therapy programs. Bonnie Wells, administrator of The Springs, the long term care and Medicare skilled nursing area for The Fountains at Canterbury, tells how The Fountains community benefits from its partnership with its rehab provider:

Why did The Fountains at Canterbury decide to outsource its rehabilitation services?

We decided to outsource from the very beginning when we began our therapy program in 1994. My background was in vocational rehabilitation, not as much in geriatrics, so I didn't feel confident enough to supervise therapy staff. Also, the market was extremely competitive for therapists at that time and they commanded high salaries. Just the thought of hiring a full-time rehab program manager was a real concern for us.

How does outsourcing your rehab fit into your facility's mission?

I think the greatest contribution of our provider is through its outpatient therapy work. With RehabCare Group's help, we have been able to educate our residents at the independent level about the benefits of our aqua therapy program. We have so many people from outside our community wanting to take advantage of the program. the public, in general, has very little awareness of what types of services are available through Medicare benefits, which really is a shame. I think people could remain independent much longer, or at least be able to maintain their current level of care, if they were aware of those services available.

What are some of the other services that an outside provider offers?

An outside provider can take a resident from skilled nursing and get her back to independent living or assisted living. Having a therapist who can follow a resident throughout her stay, and help her get on her feet again after a decline, is really a wonderful thing.

Would you recommend an outside provider to other long term care facilities?

Absolutely. One of the first things I tell people when they come here is how terrific our rehabilitation services are. Even if our residents don't have an immediate need for therapy, it's nice for them to know that they will have the very best of care if he need arises.