Multiparticipant Rehabilitation in Skilled Nursing Facilities: An Observational Comparison Study

Some But Not Too Much: Multiparticipant Therapy and Positive Patient Outcomes in Skilled Nursing Facilities

BACKGROUND AND PURPOSE

Physical and occupational therapy practices in skilled nursing facilities (SNFs) were greatly impacted by the 2019 Medicare Patient-Driven Payment Model (PDPM). Under the PDPM, the practice of multiparticipant therapy-treating more than one patient per therapy provider per session-increased in SNFs, but it is unknown how substituting multiparticipant therapy for individualized therapy may impact patient outcomes. This cross-sectional study establishes baseline relationships between multiparticipant therapy and patient outcomes using pre-PDPM data.

METHODS

We used Minimum Data Set assessments from all short-term Medicare fee-for-service SNF stays in 2018. Using generalized mixed-effects logistic regression adjusted for therapy volume and patient factors, we examined associations between the proportion of minutes of physical and occupational therapy that were received as multiparticipant sessions during the SNF stay and 2 outcomes: community discharge and functional improvement. Multiparticipant therapy minutes as a proportion of total therapy time were categorized as none, low (below the median of 5%), medium (median to <25%), and high (≥25%) to reflect the 25% multiparticipant therapy limit required by the PDPM.

RESULTS AND DISCUSSION

We included 901 544 patients with complete data for functional improvement and 912 996 for the discharge outcome. Compared with patients receiving no multiparticipant therapy, adjusted models found small positive associations between low and medium multiparticipant therapy levels and outcomes. Patients receiving low levels of multiparticipant therapy had 14% higher odds of improving in function (95% CI 1.09-1.19) and 10% higher odds of community discharge (95% CI 1.05-1.15). Patients receiving medium levels of multiparticipant therapy had 18% higher odds of functional improvement (95% CI 1.13-1.24) and 44% higher odds of community discharge (95% CI 1.34-1.55). However, associations disappeared with high levels of multiparticipant therapy.

CONCLUSIONS

Prior to the PDPM, providing up to 25% multiparticipant therapy was an efficient strategy for SNFs that may have also benefitted patients. As positive associations disappeared with high levels (≥25%) of multiparticipant therapy, it may be best to continue delivering the majority of therapy in SNFs as individualized treatment.

Skilled Nursing Facility Organizational Characteristics Are More Strongly Associated With Multiparticipant Therapy Provision Than Patient Characteristics

OBJECTIVES

Multiparticipant physical and occupational therapy provision has fluctuated significantly in skilled nursing facilities (SNFs) under shifts in Medicare reimbursement policy. Multiparticipant therapy includes group (2-6 individuals per therapist) and concurrent therapy (2 individuals per therapist). This study uses recent patient-level data to characterize multiparticipant therapy provision in SNFs to help anticipate shifts under new Medicare policy and the COVID-19 pandemic.

METHODS

This secondary analysis used data on 1,016,984 post-acute rehabilitation stays in SNFs in 2018. This analysis identified patient predictors (eg, demographic, clinical) and organizational predictors (eg, ownership, quality, staffing) of receiving multiparticipant therapy using mixed-effects logistic regression. Among individuals who received any multiparticipant therapy, those patient or facility factors associated with high rates of multiparticipant therapy provision were also determined.

RESULTS

Less than 3% of individuals received multiparticipant therapy in 2018. Patient functional and cognitive impairment and indicators of market regulation were associated with lower odds of multiparticipant therapy. Effect sizes for organizational factors associated with multiparticipant therapy provision were generally larger compared with patient factors. High multiparticipant therapy provision was concentrated in <2% of SNFs and was positively associated with for-profit ownership, contract staffing, and low 5-star quality ratings.

CONCLUSION

SNF organizational characteristics tended to have stronger associations with multiparticipant therapy provision than patient factors, suggesting that changes in patient case-mix, as expected during the COVID-19 pandemic, may have less of an impact on multiparticipant therapy provision than organizational factors. Results suggest that for-profit SNFs in states with higher market regulation, SNFs providing high volumes of therapy, and SNFs utilizing high proportions of assistants and contract staff may be more responsive to Medicare policy by increasing multiparticipant therapy provision.

IMPACT

This study may help identify SNFs that are more likely to increase multiparticipant therapy provision under new Medicare payment policy.

Therapy Staffing in Skilled Nursing Facilities Declined after Implementation of the Patient-Driven Payment Model

OBJECTIVE

The Patient-Driven Payment Model (PDPM), a new reimbursement policy for Skilled Nursing Facilities (SNFs), was implemented in October 2019. PDPM disincentivizes provision of intensive physical and occupational therapy, however, there is concern that declines in therapy staffing may negatively impact patient outcomes. This study aimed to characterize the SNF industry response to PDPM in terms of therapy staffing.

DESIGN

Segmented regression interrupted time series.

SETTING AND PARTICIPANTS

15,432 SNFs in the United States.

METHODS

Using SNF Payroll Based Journal data from January 1, 2019, through March 31, 2020, we calculated national weekly averages of therapy staffing minutes per patient-day for all therapy staff and for subgroups of physical and occupational therapists, therapy assistants, contract staff, and in-house employees. We used interrupted time series regression to estimate immediate and gradual effects of PDPM implementation.

RESULTS

Total therapy staffing minutes per patient-day declined by 5.5% in the week immediately following PDPM implementation (P < .001), and the trend experienced an additional decline of 0.2% per week for the first 6 months after PDPM compared with the negative pre-PDPM baseline trend (P < .001), for a 14.7% total decline by the end of March 2020. Physical and occupational therapy disciplines experienced similar immediate and gradual declines in staffing. Assistant and contract staffing reductions were larger than for therapist and in-house employees, respectively. All subgroups except for assistants and contract staff experienced significantly steeper declines in staffing trends compared with pre-PDPM trends.

CONCLUSIONS AND IMPLICATIONS

SNFs appeared to have responded to PDPM with both immediate and gradual reductions in therapy staffing, with an average decline of 80 therapy staffing minutes over the average patient stay. Assistant and contract staff experienced the largest immediate declines. Therapy staffing and quality outcomes require ongoing monitoring to ensure staffing reductions do not have negative implications for patients.