​A growing body body of evidence-based research has demonstrated the effectiveness of innovative physical and occupational therapy and speech-language pathology (SLP) programs in long term and post-acute care settings. Innovative programs that reduce costs, improve outcomes, and achieve patient satisfaction are just some of the objectives of the Centers for Medicare and Medicaid Services’ strategic plan to move towards a health system that achieves equitable outcomes through high-quality, affordable, and person-centered care.

On October 1, 2023, the American Health Care Association and ADVION invited four distinguished researchers to a rehabilitation symposium to discuss their recently published studies and more current findings that demonstrate the value of rehabilitation care approaches in skilled nursing facility (SNF) settings. The interactive discussion session was attended by therapy clinicians, managers, and nursing home administrators interested in implementing modern best practices to improve or maintain a resident’s optimal functional abilities. This article provides highlights of the discussion.

Variation in Employment of Therapy Assistants in SNFs Based on Organizational Factors

Presented by Tracy M. Mroz, PhD, OTR/L, and Rachel Prusynski, DPT, PhD

Mroz and Prusynski discussed the findings of a research article published in 2021 that investigated the variation of employment of therapy assistants in SNFs and the impacts on quality measures.¹ Additionally, they discussed subsequent work in this area related to organizational characteristics of where therapy assistants appear to have the most impact and whether any changes have occurred with the implementation of the Medicare Part A SNF Patient-Driven Payment Model (PDPM), growth of managed care payment models, and the disruption of the COVID-19 public health emergency.^2,3,4,5

The key takeaways were that therapy assistants are a critical part of the SNF rehabilitation team and represent approximately half of the therapy workforce in SNFs. However, therapy assistant staffing varies based on SNF organizational characteristics, such as Medicare volume, geographic location, and ownership status. Notably, therapy assistants are especially important in rural SNFs. Although the implementation of the PDPM in October 2019 and the onset of the COVID-19 pandemic in early 2020 resulted in overall reduced therapy staffing, the researchers emphasized that the “relationship between therapy assistant staffing and quality generally suggests little detriment to using therapy assistants for therapy provision in SNFs,” therefore, if used appropriately, “utilizing therapy assistants may be a cost-effective way to continue to provide services...without impacting quality of care.”

Some But Not Too Much: Multiparticipant Therapy and Positive Patient Outcomes in SNFs

Presented by Rachel Prusynski, DPT, PhD, and Tracy M. Mroz, PhD, OTR/L

On implementation of the SNF PDPM in October 2019, the practice of multiparticipant therapy increased. Currently, group therapy includes from 2 to 6 patients conducting similar activities per clinician, while the clinician simultaneously oversees 2 patients who are performing different activities with concurrent therapy. However, little was known about how substituting multiparticipant therapy for individualized therapy may impact patient outcomes. The presenters discussed the findings of a research article published in 2022 that intended to establish baseline relationships between multiparticipant therapy and patient outcomes using pre-PDPM data.⁶ Additionally, the researchers discussed subsequent work related to changes observed since the implementation of PDPM.⁷

The findings prior to PDPM implementation revealed that less than 1 percent of SNF stays included multiparticipant therapy. However, those patients receiving multiparticipant therapy for up to 25 percent of therapy minutes per stay were associated with slightly better outcomes related to functional improvement and successful community discharge. Potential benefits of multiparticipant therapy discussed included reduced social isolation, enhanced motivation to improve participation, peer feedback, and vicarious learning. Additionally, patients selected for multiparticipant therapy were less likely to have significant functional deficits, cognitive and communication impairments, behavioral issues, or neurological issues, including dementia. Those receiving multiparticipant therapy were also likely to receive intensive individual therapy, so multiparticipant therapy was a supplemental service.

With the onset of PDPM and before the COVID-19 pandemic, the use of any multiparticipant therapy increased to about 30 percent of SNF stays, while the remaining 70 percent of patients continued to receive individualized therapy during their entire stay. Notably, example data for hip-fracture diagnoses demonstrated that the overall percentage of multiparticipant minutes per stay remained much lower than the 25 percent limit permitted. However, the presenters cautioned that the increase in multiparticipant therapy use was aligned more with organizational factors than clinical characteristics, which is being further explored.
The session concluded with evidence-based examples where multiparticipant therapy can complement best practices. Short-duration high-intensity training has been shown to be more effective with specific patient populations than traditional low-intensity longer-duration approaches. Other applications of effective multiparticipant therapy include education-based groups for goals and expectation setting, strategies for problem solving and safety, fall risk/prevention, and health promotion and wellness, particularly in preparation for discharge to the community.

Experiences of Social Distancing During COVID-19 as a Catalyst for Changing Long Term Care Culture

Presented by Marion C. Leaman, PhD, CCC-SLP

Leaman expanded upon concepts from a paper published in 2021 where a parallel was made between the experience of social isolation that occurred during the COVID-19 pandemic and similar experiences occurring in everyday life for people with communication disorders living in long term care (LTC) facilities.8 For example, the COVID-19 pandemic, infection-control protocols included SNF visitation restrictions, social distancing, and masking/gowning that created an environment in which staff and residents alike experienced various degrees of social isolation. The presenter highlighted that such commonly experienced feelings of a sense of deprivation, emotional instability, social or emotional loneliness, anxiety, depression, and others are quite like the social isolation often experienced every day for years by persons with aphasia living in LTC facilities when they reside in a suboptimal communication environment.

Persons with aphasia have difficulty with speaking, understanding, reading, and writing to various degrees, but their intelligence remains intact. Adding a communication disorder on top of existing factors, such as a reduced social network, chronic disease, frailty, and vision or hearing loss, magnifies the risk for increased social isolation unless the LTC environment, including all staff, is supportive. For people with aphasia, social isolation is brought on by a lack of people who know how to communicate with them. As exemplified in a presentation slide “Living amongst a sea of people … yet I’m completely alone.”

The presenter discussed evidence and opportunities for SLPs and the rehabilitation team to leverage the lessons learned from the pandemic as a catalyst in the effort to overcome institutional and training barriers to shift the LTC culture to one that more highly values a communicative environment that is accessible to all, thereby reducing the risk of social isolation for those with communication disorders and improving overall resident and staff satisfaction. This change will require administrative support and a nominal amount of training resources to build an action plan for creating a culture valuing communication and relationships.
The article discussed included a chart detailing immediate-, near-, and long term actions that can be taken including:

• Learning and using the names of staff and residents.
• Making friendly comments.
• Sharing stories about everyday life, events, and activities.
• Showing genuine interest in others’ lives and well-being.
• Adding to or expanding upon staff communication training.
• Leveraging knowledge of staff SLPs for techniques that can be used within the course of care and do not take additional time to apply.
• Tracking outcomes of improvements resulting from a changed communication culture, including relevant clinical outcomes, resident/staff satisfaction, and even staff turnover.

Mixed-Methods Approach to Understanding Determinants of Practice Change in SNF Rehabilitation: Adapting to and Sustaining Value With Post-Acute Reform

Presented by Allison M. Gustavson, PT, DPT, PhD

Health care trends incorporating value-based payment and incentive models impacting SNF providers are driving therapists to change how they deliver care to produce better outcomes in less time. However, gaps exist in understanding determinants of practice change, which limits translation of evidence into practice. Gustavson discussed the findings of a research article published in 2021 that sought to identify various organizational and team characteristics that increase the likelihood of successful and sustainable implementation, as an organization implements disruptive changes in care delivery approaches.⁹ The key question asked in this research was “What makes SNFs successful at implementing changes that positively impact outcomes?” The study compared the characteristics of the therapists’ attitudes toward evidence-based practice and aspects of intervention implementation in the context of the organizational system, team dynamics, patient and therapist self-efficacy, perceptions of intervention effectiveness, and ability to overcome preconceived notions between SNFs that were able to successfully implement an evidence-based high-intensity rehabilitation program versus SNFs that were unsuccessful.

The results were that successful SNFs saw improvements in the short physical performance battery, gait speed, community discharge rates, reduced lengths of stay, and reduced costs of ~$1500 per stay. This was achieved without increasing treatment time or reducing therapist productivity. A root-cause analysis of low-performing SNFs showed that performance was driven by multiple factors. For example, SNFs that were unsuccessful implementing a high-intensity rehabilitation program had the following characteristics:

• They were more likely to have therapists with low self-efficacy and preconceived notions that act as barriers.
• The organizations prioritize productivity/profit rather than patient-centered care.
• There is no consistency in which therapist a patient sees or the treatment approaches of the different therapists.
• Team dynamics are poor, with no good processes for communication within the rehab team and across departments.
• There is little self-reflection or focus on results that could be tracked by using good-outcomes metrics.
• They have nursing staff shortages.

In other words, even “good therapists are no match for a bad system.” 

Suggestions were discussed highlighting management characteristics of high-performing SNFs that can foster successful implementation of new evidence-based clinical rehab programs. First and foremost is management and staff buy-in, which may require an assessment of patient-centeredness of the organizational system, the team dynamics, the degree of disruptive preconceptions such as ageism that may need to be overcome, and the therapist, facility staff, and patient belief that the new approach will be feasible and effective. Once a plan to implement is made, the clinicians must have time and space recognized to improve, which includes offering the following:

• Champions to mentor and support.
• In-clinic practice and time for reflection.
• Multi-faceted approaches to individualize needs/preferences.
• Strategies to reduce cognitive load when making practice change.
• Adequate resources to learn and apply as well as measure the success of the new practices.