Tag: SNF

When Rehab Came to Long-Term Care

When Rehab Came to Long-Term Care

For this entry of REFLECTIONS, the founders of this website decided to take a moment to reflect on our own careers in the field of Speech Language Pathology, particularly that portion that brought us together.

Way back in the very late 1980s/very early 1990s, we were both moonlighting as contractors in long-term care.  We had both come from in-patient rehab settings working with brain-injured adults and were looking to expand our skills.  Back then, SLP’s were required only on an ‘as needed’ basis in nursing homes. PT’s were required 6 hours a month and OTs were regulated to 4 hours.  There were no rehab teams, because rehab didn’t happen in nursing homes.  Nursing homes were for custodial nursing care.  If a patient had a problem, the home would call us. We would swoop in, do an evaluation and leave a long (sometimes very long) list of recommendations for the nurses to carry out.  We didn’t treat the problem.  Follow up was PRN – at the request of the nurse – if the problem didn’t resolve, given our extensive recommendations.  Thinking back, it is shocking how much we didn’t do.  Even more surprising was the fact that the head injury facility where one of us worked full time (in a department that included two other full time SLPs and two full-time SLP-As) actually occupied three wings of a four wing long-term care facility, and in five years of providing full time care, our department was called to the nursing home wing only once.

Then things changed.  In order to cut costs and defer care away from high priced hospitals, insurance companies and the federal government’s medical insurance plan, Medicare, began to reimburse nursing homes for rehabilitative care.  It was pretty much a pass through arrangement which allowed nursing homes to charge a fee for rehabilitation services which Medicare then paid.  This opened up huge opportunities for nursing homes and contract rehabilitation companies that provided rehab staff
(PTs, OTs and SLPs) to nursing homes.  This was now the mid 1990s and we found ourselves setting up departments and policies and feeding programs and language therapy in facilities that had never had them.

A population we always thought we’d just dabble in, in a setting no one ever liked, we began to love.  And then we started to teach other people (students and CFYs) to love it.  Senior citizens are awesome.  They are wise and hilarious and generous and aggravating. They allowed us into their home (the nursing facility) so that we could care for them.  It was a joy to see them improve, heartbreaking when they didn’t and an honor to shepherd them through difficult times as they approached the end of life.  The process transformed traditional nursing homes where people went to die into skilled care facilities where people lived, got better, sometimes went home or stayed and lived their lives in a place they could call home.

Then came more change.  Enter the Balanced Budget Act of 1997.  The Balanced Budget Act of 1997 was an omnibus legislative package enacted to balance the federal budget by 2002.  The Act resulted in $160 billion in spending reductions between 1998 and 2002 with Medicare cuts responsible for $112 billion of that total.  This became the real test of our love of long-term care.  We now of course, had to do more with less, but this is also when our programs started to grow and coordinate with nursing and our fellow rehab professionals.  We were a smaller more mobile band of therapists working hard to treat a population that viewed the nursing home as a short-term stop on their road to recovery. Before our entry into rehab in long-term care, no one would have ever thought that a patient would return to the community once they entered a nursing home.  Now today, most rehabilitation following surgery, strokes or general hospitalization happens in nursing homes for people over 55.

As we look back/reflect on this part of our careers, we are pleased to have been a part of the group of professionals who changed how healthcare was provided in the US. Our work extended care to millions of neglected older Americans warehoused in institutions. We improved their lives in terms of survival and opportunities to return home. In fact, you would be hard pressed to find a nursing home in the U.S., accepting Medicare dollars that does not have an SLP as part of their team. It has been our privilege to participate in this leap forward in service delivery to provide a better quality of life for our Nation’s most valuable living treasures: our parents and grandparents.

About the Authors

Marguerite Mullaney was born and raised in and around the Boston area. She continues to make her home in the Commonweath and rarely finds it necessary to travel beyond the 128 belt. Her undergraduate program was completed at Bridgewater State College and she attended Northeastern University for graduate school. Adult neurological disorders has been the primary focus of her clinical practice. Her vast knowledge of the field, thoughtful, pragmatic approach and incredible sense of humor have enlightened and inspired her patients, staff and colleagues for over 20 years.  Contact Marguerite at mullaneycccslp@comcast.net.

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com.

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The Switch

The Switch

By Michelle Sachs Clapp, CCC-SLP

Back in 1998, I was working with the geriatric population in a SNF setting. The pay was good and I enjoyed my job- at least the direct contact with my clients and the camaraderie with my coworkers. What I didn’t like was the growing amount of redundant paperwork required of me and the increasing demands and tightening criteria of what counted as “direct” or billable time.

I was forced out of this setting by the changes in Medicare standards and the fact that I was a “dinosaur” in the field- I had over 15 years of experience as a speech/language pathologist and it cost agencies or facilities a lot more to keep me on or to hire me than a more recent graduate with less experience. After being “offered” a 33% pay cut along with the promise of a pink slip in a few months, I re-examined my career choice within my chosen field. The job market was not promising for me in light of my years of experience and the pay had been cut drastically, due to the new methods of reimbursement ( direct, billable time as opposed to salaried). I had two young children and although I didn’t have to work full time, I did still have to work to help pay the bills. I decided to apply for a position with a local early intervention agency that was advertising for a speech/language pathologist.

At my interview, I feigned great interest in working with little children, even though I felt that I had little patience for this population. I played up the experience I had from years and years ago working in the Head Start program and with elementary school children. Sure enough, a position was offered to me- 2 days after I was offered a per diem position with 3 SNF’s in a not-too distant town. I accepted the per diem position. Within 2 days on the job, I knew it was a mistake. Criteria for who qualified for my services severely restricted who I could work with, regardless of my professional opinion of who would benefit from my assistance. I could see that I would be spending a lot of time with minimal financial reimbursement. And the paperwork was quite overwhelming as well.

I called the early intervention agency that had offered me a position and indicated to them that I was still interested in them, if they were still interested in ME. They called back and our partnership began.

For the first year of my new career with little ones, it felt like I was paddling upstream; it had been years since I had worked with pediatrics and I was behind in skill, knowledge, lingo, etc. I worked directly with the children and their families during the day and studied and read up on pediatrics on my own in the evenings. After my first year there, I finally felt comfortable enough to start widening my knowledge base by taking on a more varied caseload, reading additional materials about non-speech/language issues with this very young population, and really listening to and doing co-visits with my non-SLP co-workers.

To summarize, I am now completing my 11th year working in early intervention! I love what I do. I feel like I rediscovered my field of work and put my heart into what I do. I feel very alive in my daily work and the rewards are priceless. The pay may not be as much as it is now in SNF’s, but the benefits (being paid with hugs, kisses and holiday photos) more than make up for the lack of monetary compensation. Way back when, when I was applying for this position, I thought that I was faking my enthusiasm about this population but much to my surprise, I discovered that I love love LOVE working with these little ones and their families! I have plenty of patience for them; I guess it was my OWN kids that I had the lack of patience with! Although, as I get a bit older, it gets a bit harder getting up and down off of the floor from my visits, I will continue to do so for as long as I can and will continue to learn about and take on the various challenges that working with the 0 to 3 year old population holds for me.

Michelle Sachs Clapp MA CCC SLP graduated from University of Delaware with a BA in Communications and completed her MA at Ohio University. Since entering the field, she has worked in a variety of treatment settings but finds her current position in early intervention to be her favorite. In addition to her career in Speech Language Pathology, she has honed her parenting skills over the years raising a daughter, son, and soon to be stepdaughter. Her happy home life is fully rounded out by the love and affection of her cat and dog. She has practiced Kundalini Yoga for the last 9 years which maybe how she maintains her charm and humor when life presents unexpected changes.

Michelle is a good friend and an excellent clinician. It was a distinct privilege to work with her so many years ago when our careers as SLP’s were shaken to the core by PPS. I am honored that she agreed to share her method for dealing with the January 1999 reimbursement changes for SNF’s. These regulations continue to test the patience and ethics of individual practitioners across the country. As we prepare for the next round of changes, Michelle’s experience serves as a timely reminder of all the opportunities our profession affords us.…

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Unreasonable and Senseless

Unreasonable and Senseless

By Marguerite Mullaney

Unreasonable and Senseless

The cornerstone words in all rehabilitation treatment plans are reasonable and necessary. They have been the yardsticks by which our Medicare reimbursement intermediaries retroactively determine if a claim for service is covered under the Medicare A benefit or Medicare B plan. Seventeen years ago when I first walked into a nursing home and began to learn the rules for providing rehabilitation services in a Skilled Nursing Facility (SNF), reasonable and necessary were applied to every goal of each individualized treatment plan written for our patients.

I might mention, those plans were handwritten by the evaluating therapists. The goals were often agonized over to be sure they fit the reasonable and necessary parameters and could be measured should proof be needed of the final outcome. Way back in the 90’s, the therapist writing the goal was more than likely to be the person carrying it to completion. PTA’s and COTA’s were utilized as an additional resource but not the primary therapist responsible for weekly updates, monthly recertification, home evaluations, and discharge summaries. In short, they assisted the registered clinician in carrying the caseload. Then as now, Speech Language Pathologist cannot use an SLP assistant at SNF level and receive Medicare reimbursement as our PT/OT colleagues can. This means an SLP carries a caseload in much the same way he/she did almost two decades ago.

The rules changed in January 1999. The Prospective Payment System arrived! It was designed to cut Medicare waste and fraud. It was marketed as a means to control the spending at the SNF level which was rocketing out of control. Many inside the industry puffed about the system forcing ‘smaller players’ out of the market thereby cutting the ‘glut’ of skilled beds. We were being told at the time there were 1000 too many skilled beds here in Massachusetts. The extra beds were alleged to be driving up the cost of care.

I have a question: Our entire economy is based on supply and demand. Has there ever been another industry that drove the costs of services up when the supply was greater than the demand?

We are on the eve of adjustments to the reimbursement system. I’ve been told the regulations are going to get even tighter. To be honest, other than knowing rules will be added in October 2010, my knowledge of the changes are very limited. However, I feel qualified based on almost two decades practicing in SNF’s to make a prediction: Nationally based For Profit Corporations will become the primary providors of skilled care beds across the United States.

I have a second question: Large, nationally based for-profit corporations are created to make money and increase profits for their investors. Who will be paying the biggest piece of that revenue? Individuals? Private Health Insurance Companies? The US Government via Medicare/Medicaid?

I might mention here that regardless of clinical setting, the best reimbursement source for an inpatient rehabilitation stay is Medicare. Yes, the same system that was redesigned to control costs in January 1999. It is the system For-Profit Healthcare Providers want well-represented in their case mix. More than want, they rely on Medicare to make their bottom-line.

Here’s a rhetorical question for those who think I’m overstating the value of Medicare A and B to SNF’s: When was the last time anybody heard an Admission’s Director say they needed to fill more beds with Medicaid recipients?

I’ve watched over the last few years as the terms reasonable and necessary have been morphed into new packaging. Many rehab providers are using software systems that have goals listed and waiting to be plugged into an evaluation. Some software triggers the goal a therapist should pick. There are courses with watch words and buzz words to prep therapist to avoid writing an evaluation or a note with a RED FLAG. I’m a realist. I know those types of formulaic programming are a natural outcome of Intermediary Help Letters, Denials, and the dreaded RAC Audits. There is nothing wrong with giving therapists tools to practice within reimbursement guidelines.

But, something more insidious happened while I was distracted watching the major changes. A phrase entered the continuum of care very casually. In fact, it sounded like a good thing on first blush. It wasn’t until it was applied against the stark white of reality, that I truly understood the danger of the concept.

“We treat all our new admissions as ultra highs until they show us differently.”

It doesn’t sound bad. It actually captures the spirit of America. Everybody gets a fair and equal shot at their bite of the apple. Makes you think the care providers don’t pre-judge based on gender, race, sexual orientation, age, or ability. Sounds like equal protection. But, this is exactly the point where everything goes wrong.

We do an evaluation so we can pre-judge and prescribe the appropriate amount of treatment. Our recommendations are supposed to be based on what the patient is able to do during the evaluation. We must take into account their general health prior to illness, their premorbid level of daily activity, the course of their illness, their age, their family’s goals, and their own hopes for their recovery. We adjust the patient’s goals as the treatment plan succeeds or fails. Weekly notes and monthly recerts are there to keep us and the patient focused on progress, or lack thereof.

However, if the expectation walking in the door before we even lay eyes on the patient is that this very sick individual who has been in acute care for at least 3 midnights is to be able to tolerate a minimum of 35 minutes of treatment per day by 3 disciplines over 7 days with 3 hours of group time being evenly divided among disciplines, then the evaluation is completely superfluous.

Most nurses and aides and family members already know a patient cannot walk, eat, talk, or care for themselves. The therapists’ evaluation is meant to provide a means of rehabilitation and a plan of implementation. Computers are able to generate goals based on assessment data of strength/weakness. Assistants for PT/OT carry out most of the plans of care. And, now registered therapists have pretty much lost their authority to determine how much time is needed per day and how many days in a row are necessary to reach functional potentials.

I fear, we registered therapists across disciplines have just become rubber stamps for a plan of care designed, programmed, and packaged to meet the standards of a reimbursement system extracting the maximum dollar amount for care provided to any patient, regardless of their reasonable and necessary needs.

About the author

Marguerite Mullaney was born and raised in and around the Boston area. She continues to make her home in the Commonweath and rarely finds it necessary to travel beyond the 128 belt. Her undergraduate program was completed at Bridgewater State College and she attended Northeastern University for graduate school. Adult neurological disorders has been the primary focus of her clinical practice. Her vast knowledge of the field, thoughtful, pragmatic approach and incredible sense of humor have enlightened and inspired her patients, staff and colleagues for over 20 years.

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