Under Pressure Speech-language pathologists in many skilled nursing facilities report high productivity expectations amid sweeping changes in health care delivery. And they’re speaking out about the effect of these expectations on patient care and service delivery. Features
Features  |   June 01, 2014
Under Pressure
Author Notes
  • Matthew Cutter is writer/editor of The ASHA Leader. mcutter@asha.org
    Matthew Cutter is writer/editor of The ASHA Leader. mcutter@asha.org×
  • Carol Polovoy is assistant managing editor of The ASHA Leader. cpolovoy@asha.org
    Carol Polovoy is assistant managing editor of The ASHA Leader. cpolovoy@asha.org×
Article Information
Special Populations / Older Adults & Aging / Healthcare Settings / Professional Issues & Training / Features
Features   |   June 01, 2014
Under Pressure
The ASHA Leader, June 2014, Vol. 19, 36-44. doi:10.1044/leader.FTR1.19062014.36
The ASHA Leader, June 2014, Vol. 19, 36-44. doi:10.1044/leader.FTR1.19062014.36
Like many speech-language pathologists, Rachel Wynn took up the profession because she wanted to work with adults who needed her help. It wasn’t her first career—but when she discovered she’d need a master’s degree to continue in her original career of university admissions, she looked for a new field. She’d always enjoyed getting to know people, finding out about their difficulties, and guiding them toward personalized solutions that would improve their lives in meaningful ways. So speech-language pathology—with its focus on one-on-one treatment—seemed like the perfect choice.
But what Wynn experienced in the first week of her clinical fellowship at a skilled nursing facility stood in stark contrast to the work she’d imagined—and forever altered her view of the profession.
“When I graduated, I had no idea what to expect working at a skilled nursing facility,” Wynn says. “I was told I would have a week of observation and training. I actually had about a day. I saw patients the next day … and by day three was working like any other therapist on staff. I was completely unprepared.”
Soon it became apparent that Wynn’s employer expected her to complete documentation on her own time, and spend her time on the clock working to meet the facility’s 85 percent productivity requirement (85 percent of time on the clock must be spent in face-to-face treatment). Every patient was categorized as needing the highest level of rehabilitation services; all patients received speech therapy—whether they needed it or not, in Wynn’s clinical judgment; and managers overturned Wynn’s decisions not to treat certain patients, altered therapy minutes in Wynn’s documentation, and asked her to limit her evaluation time. Managers even denied her recommendation to discharge a dying patient.
Wynn may have been a novice clinician, but she wasn’t wired to wilt under organizational pressures, however concerted they appeared. When her protests went unanswered at the facility, she contacted ASHA ethics staff, as well as the Medicare fraud hotline and Texas Wage and Hour Board. (She was later advised by her U.S. congressional representative that despite the lack of response from Medicare, the agency does collect and record these complaints.)
Unfortunately, there was little either organization could do to help—beyond recommending that Wynn hold tightly to her professional ethics in all such situations. So Wynn took a drastic step: She quit her clinical fellowship two-thirds of the way through and finished it at another facility.
But she often thought of the patients with whom she worked. The one she’d twice attempted to discharge, only to have the patient be reinstated by her managers both times. The patients nearing the ends of their lives who’d been given therapy regardless.
“It’s appalling,” Wynn said, “that we’re treating elders this way.”
Payment and productivity
Why are treatment conditions so appalling—in Wynn’s parlance—in some skilled nursing facilities? The push to provide high levels of speech-language treatment and occupational and physical therapy stems from Medicare’s reimbursement system. SNFs receive reimbursement for therapy services under Medicare Part A (covering inpatient services and hospital stays) or Medicare Part B (covering medical or outpatient services), depending on the patient’s status.
Part A (which covers a significant number of SNF patients) pays facilities a daily rate that covers all patient expenses, including speech-language and other therapy. In this system, each patient is classified into a “resource utilization group”—known as a RUG—based on an assessment of how much therapy and other services the patient needs. The patient’s RUG determines the daily reimbursement rate. More therapy and other services equal a higher RUG which, in turn, equals a higher daily fee to the facility.
Only face-to-face treatment time counts toward the patient’s prescribed therapy minutes. (See “How Medicare Reimbursement Works in SNFs” for more explanation.)
Medicare instituted this system in 1998 to control upwardly spiraling costs. But third party-evaluations reveal flaws: A 2012 Urban Institute report to the Medicare Payment Advisory Commission notes that “the system did not accurately pay for nontherapy ancillary services [and] encouraged facilities to provide therapy services for financial, not clinical, reasons.” And as early as 2001, an Institute of Medicine report on the overall U.S. health care delivery system found “substantial evidence documenting overuse of many services—services for which the potential risk of harm outweighs the potential benefits” (see sidebar).
SLPs and other therapists see the effects of this payment system daily in some SNFs. Many report pressures to provide services to patients who don’t need or want them, and to maintain prescribed productivity levels that may approach 100 percent. “Productivity” includes only face-to-face time with patients, because other activities do not count as “therapy minutes” under the Medicare RUG system. SLPs must complete thorough documentation to justify treatment, plan treatment, consult with other health care professionals, educate family members, get from one patient to the next, even use the restroom in the remaining time. In an eight-hour day, a productivity requirement of 85 percent—common in many facilities—leaves 72 minutes for all these activities.
Some SNFs are trying new models to ease productivity pressures, but given the economic incentives, productivity is king in many SNFs.
The rule, not the exception
Wynn isn’t the only SLP in a skilled nursing facility experiencing pressures and frustration—far from it. In October 2013 she started a blog, now incorporated into her Gray Matter Therapy website, and in November spearheaded a letter-writing campaign to ASHA, state organizations, legislators, company ombudsmen—anyone who would listen. “It’s not an isolated problem,” Wynn said. “It’s the rule, not the exception.”
Lending weight to Wynn’s claim, physical and occupational therapists also report feeling productivity pressures. Maureen Peterson, chief professional affairs officer of the American Occupational Therapy Association, and Anita Bemis-Dougherty, clinical practice director of the American Physical Therapy Association, have received a host of similar concerns from their members.
Wynn drafted a form letter for other SLPs to draw from that outlines general concerns with SNF working conditions: lack of respect for SLPs’ clinical judgment, productivity demands, decreased compensation and increased expectation to provide one’s own materials. Wynn encouraged letter-writers to note that many SLPs are quitting their jobs—with no other employment—and clinical fellows are being hired to fill the positions.
The letters ASHA received describe situations that run the gamut from illegal to unethical to inappropriate—but all bear an uncomfortable similarity to Wynn’s travails during her clinical fellowship.
  • “My soon-to-be-former employer rejects my requests to discharge patients who have met their therapeutic potential or who are simply no longer candidates for therapy.”

  • “I have to treat every patient at an ultra-high minute level, and less minutes are not an option … and then, ultimately, I can only accept a patient refusal if the patient is dead.”

  • “I—as well as the occupational therapist and physical therapist—was forced to see a patient who was unconscious and dying for hour-long sessions.”

  • “I confirmed that my manager had increased my minutes on a patient to bump that patient from a ‘very high’ to ‘ultra’ billing category. Luckily, I was able to switch the minutes back myself and avoid any fraudulent billing.”

Productivity demands
Unrealistically high productivity expectations—often 85–100 percent—are a major concern among letter-writers. According to Wynn’s letter, the time does not include necessary nonbillable services including conducting Medicare A evaluations, speaking to nurses, calling families, consulting with colleagues, charting, and conducting and attending in-services and meetings. Employers are increasing productivity expectations and tying them to pay, noted some letter-writers, but these employers don’t provide sufficient resources to make the expectations feasible. Specific instances include:
  • “They determine how long each patient will be seen each day—and it varies greatly from day to day—based upon how many minutes each discipline needs in order to keep each therapist ‘productive’ at a 90–92 percent expectation for an eight-hour work day, while keeping each patient at the highest possible reimbursement level.”

  • “Rather than dealing with daily reprimands about productivity, I usually clock out to do documentation, make family phone calls, and even go to the bathroom. Working off the clock is disrespectful to the profession as a whole, though it’s the choice some of us feel forced to make.”

  • “I have responded to the increasing pressures by putting in more hours off the clock to complete all of the job requirements that simply are not contemplated in my employer’s definition of 92 percent productivity.”

  • “I was reprimanded at one facility when I did not meet their 85 percent productivity standards because I took 40 minutes on the clock to read therapy and chart notes on the seven patients I was treating that day in order to give them the best treatment possible.”

In response to the letters, ASHA hosted an online chat on Dec. 12, 2013, “Employment Issues in Long-Term Care: Productivity, Ethics, and Fraud”. More than 200 SLPs logged in to express their concerns; the flood of more than 650 comments was too great for the moderator to post them all. The chat had been replayed on ASHA’s website 425 times by the end of March.
Although not all chat participants expressed productivity concerns, most did, and they voiced frustration at not being able to find help. Addressing this concern, Janet Brown, ASHA director of health care services in speech-language pathology, noted that the association “is not a union and cannot arbitrate on [members’] behalf. However, we develop resources that are on the Web, and are happy to consult with you on the phone or via e-mail” (see sidebar).
In March an extensive thread sprang up on the Special Interest Group 13 discussion board on the ASHA Community, with nearly 50 health-care–based SLPs chiming in to recount their experiences completing documentation off the clock, being asked to provide inappropriate services, or otherwise grappling with their facilities’ high productivity requirements. Again, not all of the posted experiences were negative, but the responses paint a less-than-rosy picture of therapy services—primarily in skilled nursing facilities.
These complaints aren’t merely anecdotal: At least two lawsuits allege that companies filed fraudulent Medicare claims based on artificially high therapy targets—Life Care Centers of America in 2008 and Aegis Therapies Inc. in 2010.
According to court records from the Aegis suit, whistleblower Ricia Johnson said she “witnessed Aegis’s physical therapists negotiating over who would get to claim Johnson’s time as their own that day in order to meet Aegis-established individual productivity goals.”
Court documents also indicate that Life Care set aggressive targets for “ultra high” therapy levels “that were completely unrelated to its beneficiaries’ actual conditions, diagnoses or needs.” The company allegedly pressured therapists to reach the targets through corporate presentations, visits from top company officials and action plans for underperforming facilities.
Productivity perspectives
Given health care’s ultimate goal of improved care and the recent push toward patient-centered care and measurable patient outcomes, many ask whether higher productivity requirements are the best way to achieve these goals. Experts and professionals weighing in on the issue, however, have opinions that range from total rejection of productivity measures to enthusiastic support, albeit with a few caveats.
Medicare doesn’t issue productivity guidelines or recommendations; the facility or its rehab contractor set them. At their best, productivity requirements increase efficiency and are calculated to allow therapists time for other tasks in the building—consultation with professionals and families, documentation and so forth. But when productivity requirements rise as high as 100 percent, therapists state that they cannot provide the best treatment possible for the patient.
SLP Michael Hoeft maintains that the debate itself is useless. “As long as skilled nursing facilities see productivity as a good thing,” said Hoeft, director of rehabilitation at Redington Fairview General Hospital in Skowhegan, Maine, “you can’t win,” even if you include other tasks in the productivity formula.
“The industry is in a death spiral,” Hoeft said. “To get productivity up, managers cut hours, and send therapists home based on the patient census. It’s wrong for the staff: It kills morale, because therapists never know how much money they’re going to make. It’s wrong for the organization: Employees leave because they don’t like the work environment, and then capacity drops,” he said.
The bottom line? “It’s dangerous to look at labor as a variable cost,” said Hoeft. “People are not variables. People are your programs.”
Garry Pezzano, Genesis Rehab Services senior vice president for clinical practice, disagrees. “Productivity as a measure is not new to any service organization,” he said. “The asset is staff, the product is service, and one measure of performance is productivity.”
Pezzano, an SLP and president of the National Association for the Support of Long-Term Care, says that Genesis—which provides therapy services to 1,600 facilities in 46 states—doesn’t have a published productivity requirement. “The expectation is, on average, 75 to 77 percent. We have invested in electronic documentation and handheld devices to make bedside documentation more feasible. There’s a communication system built into that so that therapists don’t have to make as many return trips in between patients. We don’t measure or hold people to productivity levels, but we do have a guide for best practices.”
However, Pezzano also notes that Genesis department managers receive bonuses based, in part, on their staff’s productivity.
But Genesis also has demonstrated commitment to measuring patient outcomes: It is the first health care provider to participate system-wide in ASHA’s National Outcomes Measurement System. Genesis has embedded the NOMS data collection elements—including functional communication measures—in its internal system, and is working with ASHA to build a mechanism to export the data into NOMS.
To economist Gail Wilensky, a senior fellow at Project HOPE and former senior health and welfare adviser to President George H.W. Bush, productivity’s benefits or disadvantages are an empirical issue that depends on how the requirements affect quality of care. “What metrics do we have to show that increased productivity requirements lead to declines in quality?” Wilensky asks. “Productivity can be improved and result in improved quality of care.”
With health care reform calling for even greater reimbursement reductions, Wilensky sums up the health care environment as “tough ... doable but tough.” And although she supports productivity measures as a means to provide better quality care, she cautions that the way each facility sets up its practices has a big effect on outcomes.
Costs and quality aren’t necessarily trade-offs, Wilensky says, and it makes sense for facilities to measure productivity to improve care. “But,” she adds, “you must include outcomes.” Looking for improvements and decrements in outcomes, and adjusting for health risks, are crucial. The question, Wilensky says, is “How do we have the process function efficiently, yet encourage the best health outcomes?”
But to Hoeft, productivity does not necessarily equal efficiency, especially in a service-oriented field such as health care. “I have never seen an organization be highly successful—in terms of patient and public perception and financials—by turning to a productivity approach,” he said. “Productivity requirements are arbitrary figures. Why specify a [productivity] number? There’s no math formula that defines which is best. It sounds like more is better, but that’s the first mistake: Productivity does not equal efficiency. Productivity numbers don’t correlate with anything.”
Carving a new model
Recently, several organizations have partnered, chisels in hand, to effect change. In 2013, the Centers for Medicare and Medicaid Services contracted Acumen LLC and the Brookings Institution—an independent D.C. research and policy think tank—to help them explore alternate payment systems for skilled nursing facility therapy services. The recently released Acumen report identifies two payment model concepts for development and analysis.
The first, the resident characteristics model, uses existing practice patterns to develop an empirical model of the relationship between resident characteristics and expected costs of therapy care. The second, the hybrid model, uses a case-mix classification system but combined with a resource-based pricing adjustment.
When contacted, the CMS press office declined to answer questions about how nonbillable patient-related tasks and Medicare documentation burdens affect productivity, and whether the SNF reimbursement system incentivizes facilities to classify patients in higher RUGs than appropriate.
Some providers already do things differently, based on the concept that better patient care—not productivity requirements—leads to better outcomes, which in turn lead to satisfied patients who recommend the facility to others, driving up revenue. Janet Mahoney—CEO and founder of health care start-up Arete Rehabilitation in Amesbury, Mass.—is recruiting therapists, and so far she has been “inundated with applications from SLPs who want to work with a different philosophy,” one that values the highest-quality services over the amount of time spent with patients.
Arete Rehabilitation contracts with skilled nursing facilities—one, so far—to provide therapists. The contract is based on staffing needs and patient census over the past 12 to 24 months. “As volume ramps up,” Mahoney said, “our cost remains the same, allowing the facility to make money.” Mahoney believes facilities will achieve growth, not in spite of her therapists’ increased ability to spend on nonbillable clinical tasks—but because of it.
For Mahoney, professionals of varied fields collaborating on the best-quality care is a better efficiency indicator than artificial productivity requirements that are, Mahoney said, “a detriment to quality, to patients, to the facility. Patients don’t receive the highest quality services we can provide.”
Other facilities’ stories bear out Mahoney’s philosophy. Michael Hoeft of Redington Fairview General Hospital said that, “Regardless of payer source, the factors of financial success are completely dependent on the success of being able to create—in the patients’ perspective—a high-quality institution and, therefore, a high-quality therapy program. You’ve got to get the patients in the door, and they have to exit saying, ‘I had a good experience, and I’m going to tell everyone about it.’ You don’t want negative comments, which spread 10 times more quickly than positive ones.” Hoeft took that very pitch to Redington Fairview’s administration and convinced them they could make more money without a productivity requirement than with one.
The results were even more positive than Hoeft anticipated: The hospital’s therapy department has seen good financial returns by focusing on building a stable, long-term, high-quality therapy program—one that focuses on retaining talented staff and providing outstanding patient outcomes. The therapy staff has grown from six to 40, and they’ve seen steady growth in patient volume and customer satisfaction scores. Hoeft explained, “You recruit good therapists by creating a good home for them. Give them the tools and atmosphere to do the great work they’re trained to do. No productivity requirements—just happy patients—will make money. Excellence is the key.”
Loretta Wright, director of rehabilitation at Frasier Meadows retirement community in Boulder, Colo., is encouraged that SLPs are voicing their concerns so strenuously. With regard to service provision, “in the last 10 to 11 years,” she said, “the amount of arm-twisting in long-term care has ramped up markedly.”
When Frasier Meadows considered bringing in a management company to handle therapy services, Wright and her co-director presented an alternate plan. They would hire a full-time SLP and set their own productivity guideline, with the understanding that hitting a given productivity number wasn’t always feasible. As a result, revenue tripled, and they were able to bring in more Part A patients. Among patients, Frasier remains a sought-after facility—maintaining, on average, a 95–98 percent census—with low staff turnover.
“People who are discharged from Frasier Meadows tell other people about their care. And when those other people land in the hospital, they tell the discharge planners that they want to go to Frasier,” Wright said. “There are a lot of [skilled nursing] choices here, but we’re always full.” The gains made by individual facilities may be heartening, but they don’t help the SLPs working under productivity pressures who have bills to pay and families to support. In some locations, the facility might be the only source of SLP employment. And some SLPs are hesitant to complain about such policies, fearing they’ll be fired. What can you do if your facility is the only game in town?
“Go for the low-hanging fruit,” Wynn suggests. “Take on one thing each month: I’m going to do full evaluations, or I’m not going to work off the clock, or I’m not going to provide therapy to someone who doesn’t need it. It’s a huge problem, and we need to chip away at one little block at a time.”
Why Some SLPs Work Off the Clock

Because of productivity expectations, some SLPs complete tasks on their own time.

At 85 percent productivity SLPs must provide direct treatment for 408 minutes in an eight-hour day, leaving 72 minutes to complete nonbillable tasks.

At 90 percent productivity SLPs must provide direct treatment for 432 minutes in an eight-hour day, leaving 48 minutes to complete nonbillable tasks.

At 95 percent productivity SLPs must provide direct treatment for 456 minutes in an eight-hour day, leaving 24 minutes to complete nonbillable tasks.

Nonbillable tasks

  • Gather materials and walk to each patient’s room.

  • Persuade patients to agree to come to the treatment session.

  • Call families for status updates and discharge planning recommendations.

  • Attend care plan meetings with families, nurses, social worker, physician and others.

  • Screen new patients or those flagged by nurses.

  • Complete documentation for evaluations, treatment sessions, discharge summaries, weekly progress notes, 30-day recertifications and other patient activities.

  • File copies of documentation in paper charts.

  • Attend therapy team meetings to collaborate to improve patient outcomes.

  • Consult with other professionals about complex patient cases.

  • Educate nurses and assistants about diet texture changes.

  • Review patient reports from modified barium swallow studies, prior speech-language treatment, gastroenterology, otolaryngology and other specialists.

  • Solve problematic behavior and communication challenges, and train nurses and assistants to implement strategies.

  • Conduct staff in-service training to ensure appropriate referrals and provide appropriate cueing and assistance to maximize safety and independence.

  • Troubleshoot computer and documentation software issues.

  • Copy and prepare materials for treatment.

  • Read e-mail and written notes from managers.

A Call for Health Care Change

Concerns about U.S. health care delivery are not limited to rehabilitation or to skilled nursing facilities. The delivery system has “floundered in its ability to provide consistently high-quality care to all Americans,” stated a far-reaching and pivotal report from the Institute of Medicine in 2001. “Between the health care we have and the care we could have lies not just a gap, but a chasm.”

The Institute of Medicine is an independent, nonprofit organization that provides advice to decision makers and the public. The 2001 document, “Crossing the Quality Chasm: A New Health System for the 21st Century” called for fundamental change to close the quality gap and recommended a redesign of the American health care system to one that is safe, effective, patient-centered, timely, efficient and equitable.

In one of its five agenda items, the report calls for a framework that better aligns payment and accountability incentives with improvement in quality, noting there is “substantial evidence documenting overuse of many services—services for which the potential risk of harm outweighs the potential benefits.”

Any new payment framework should reward high-quality care and foster value-based, effective care—regardless of whether the care environment is competitive or regulated. Payment systems should be patient-centered, evidence-based and systems-based, and should:

  • Provide fair payment for good clinical management of the types of patients seen.

  • Allow providers to share in the benefits of quality improvement.

  • Allow consumers and purchasers to recognize quality differences in health care and direct their decisions accordingly.

  • Align financial incentives with the implementation of care processes based on best practices and the achievement of better patient outcomes.

  • Reduce fragmentation of care.

The report noted that incremental improvements could strengthen quality in existing payment method but that real change will come only through more significant reform.

“With this conclusion, the Institute of Medicine explicitly recognized—more than a decade ago—that financial incentives need to be aligned with achieving high-quality patient outcomes,” said Margaret Rogers, ASHA chief staff officer for science and research. “Under this type of pay-for-performance system, there would be no incentive to provide services that may be unnecessary or ineffective, as is unfortunately encouraged in current fee-for-service systems.”

— Carol Polovoy

ASHA Efforts and Resources

Inflexible productivity requirements affect more and more clinicians in health care and pose a potential threat to patient care and clinician satisfaction. ASHA is working to raise awareness of the risks of excessive productivity requirements on quality health care.

For more information on these issues and a host of helpful resources, see “The Push to Preserve Clinical Judgment,” The ASHA Leader, Feb. 2014 and “Audit-Proof Your Documentation,” The ASHA Leader, Aug. 2013.

May 31, 2014
Denise Rogers
Response to "Productivity"
Some of you may remember my rants about this on the old SID 13 Listserve...over NINE years ago! Exposing the widespread abuse of healthcare professionals (and the patients they serve) has been a long time coming. Just to acknowledge that what we were experiencing was real and not the result of our failed skills or inability to conform to workplace culture appropriately is a leap in the right direction. Brava, Rachel Wynn, for your tenacious efforts to expose this and for ASHA to admit that this is the rule, not the exception, in the SNF environment. THAT is advocacy for your membership! Now you must take it to Capital Hill on our behalf. And to my colleagues: "Don't Stop Believing"...
May 31, 2014
Marisa Parker
This article is informative, i was unaware that so many SLPs felt this way . Personally, I am probably the exception, I don't feel this way. I actually feel that my opinion is valued . Productivity standards are high, but I feel doable . Many clinicians do not know how to balance productivity standards . It is definitely stressful and busy, but that is why SNF is the highest paid. If you don' t advocate for yourself , no one is going to do it for you . I know many will disagree. I am mainly posting to say that not all SLPs agree w this article, even if it's just me. I love being busy and rise to any challenge .
May 31, 2014
Jennifer Kleber
Maybe, maybe not
I work at a SNF where the productivity standard is 80%. Most days, however, I get between 85-87%. Granted, some days I am in the upper 70s but overall I don't feel stressed about productivity at this level. It was hard to learn how to balance it all but once I figured it out, my days of 83% productivity are the days in which there is a LOT of paperwork to file or nursing wanting to talk, etc. I wonder if a lot of the issues may lie in how big or spread out the facility is, but at least where I am which is about 37 beds, 85% average wouldn't be unreasonable. Now, 90%..... I could see some challenges.....
May 31, 2014
Jennifer Shagan
SO true
I am a traveling SLP and I have had quite the sampling of SNF's. This is the rule and the working conditions are extremely stressful. Productivity is an arbitrary means of measuring all the intangible services we provide. We don't work with numbers we work with people. As SLP's without union representation it is very hard to have representation in our court. Something to think about. Refuse to work off the clock. I didn't go to school and have student loans to work for free.
May 31, 2014
Nannette Crawford
This article is a good start to awareness...it needs to go national. The public needs to be aware of what the nursing home environment is like for most therapists. And more importantly how it affects the treatment that they or their family member is receiving. The fraudulent billing practices are pervasive throughout the industry. Hard work is not the issue. It is the way in which 'productivity' is defined by most rehab companies. It must be made very clear to the public when therapists are asked to be 'productive' for 80-100% of their time, all aspects suffer. Point of service documentation is not the answer during most sessions as the patient is not really receiving intervention while the therapist types. It may be feasible when taking a case history but other than that one of the two functions suffers: inadequate documentation or inadequate therapy in MOST cases. Actually both become inefficient (documentation and therapy). Thank you Rachel Wynn and ASHA.
May 31, 2014
Alisa Schwegerl
Not the way in all SNFs
I have been an SLP in SNFs for over 20 years and while there is productivity standards/ expectation/ guidelines, this article does not represent all companies or facilities. While it is a business and the facilities should be adequately reimbursed for all therapy services provided that are clinically reasonable and relevant, in no way should employers be disregarding the clinical judgments of the therapist. No facility I have ever worked at in 20 years has been all about the productivity or about the RUG level. It's unfortunate and disappointing that so many feel the opposite or have experienced this, but to generalize that all SNFs and rehab companies have this same mismanagement and pure lack for patient care and ethics is certainly not true.
June 1, 2014
Denise Rogers
response to clinicians in "good" working environments
Perhaps those of you who have had what you report to be acceptable working conditions in SNFs would like to share the names/cities of the places you've worked? I'm sure there are many folks out there in less than desirable situations that would welcome a new job, if a position were available...
June 2, 2014
Kristen Miller
In my 12 years experience of working in SNF's I've seen both sides. I wouldn't feel comfortable naming names, but I will say that with SNF's run by national therapy services/companies the push was always about productivity. They spent so much time drilling and training on productivity expectations I actually found it to be an oxymoron or a crazy waste of time. With independently run SNF's which were privately owned, hospital based, or county facilities (not based on national chains) I never experienced the productivity demands. One might keep this in mind when considering employment. There is a job opening near me which advertises a $90,000 a year salary for a SNF run by a therapy department supplied by a national chain. The rehab company within the facility frequently changes names and/or ownership with a large chain; however, the productivity demands always remain the same. The number of beds at the facility and/or patient types at the facility do not even support the need for a full-time SLP. One might also keep this in mind when considering employment.
June 3, 2014
Rachel Wynn
Productivity Survey
I'm collecting data on productivity expectations in SNFs. It's a short 60-second survey and I'd love your help. Please complete and share with SLPs, OTs, and PTs. https://www.surveymonkey.com/s/6KDJMNL
June 4, 2014
Michael Hoeft
Not just SNFs
To meet an arbitrary productivity standard of 70 or 80 or 90%, mathmatically...one is faced with either increasing patient billables or cutting non-billable time. Other than see a given caseload for more minutes -- seen as often not an ethical option -- I am not sure how an SLP at a SNF or hospital actually increases patient billables? Are they not dependent on the facility admission process and the profile/needs of the incoming patients? Therefore, to increase productivity, the SLP is left to coming up with ways to reduce non-billable time. And that, I argue, is a losing venture right from the onset. Yes, we should be efficient...and with most organizational time study analysis we often can find simple time-saving and supportive methods to acheive such ends, But too often, the SLP is simply told the magic number and expected to get there by whatever means...albeit cutting their labor hours (the quickest solution) or taking multi-tasking to new levels. Either way, we lose. We are chasing the proverbial mechanical rabbit. While I am glad to hear that some us are fortunate enough to work in environments that have less than rigorous productivity measures, I wonder then why have them at all? Why give these pulled-from-the-arse numbers legitmacy? Why not simply focus on producing high quality patient outcomes and employ management/admin to get more patients in the door or help design internal systems that allow the SLP more time to do what matters most. to acheiving the one thing that can directly influence referral rates -- high quality outcomes.
June 4, 2014
Michael Hoeft
One more thing
I also am seeing/hearing a growing number of large healthcare organizations impose productivity standards that is resulting directly in PT, OT, and SLP hours being cut. I know of one large hospital cilnic who has recently gone this route and as a result, staff come in each day not knowing how many hours they will work; dependent on that day's caseload, cancellation rate etc... They are expected to reduce their work hours as needed to keep 75% "producive" Hmmm....wonder when that number will be adjusted up to 80 or 90% More is better, right?
June 9, 2014
Sean Godfrey
The elderly as a source of profit
The title of this comment is from this article: http://bit.ly/1pctmcQ It's very relevant regarding illuminating multiple sides of this dilemma -- a dilemma in which many SLPs find themselves caught between profiteers and patients. Deep breath... After my experience of being told I'd have a full-time job waiting for me at the end of a one-thousand mile family relocation, only to actually have a ~20 hour/week PRN position at a locally respected SNF where I was told to pick up unqualified* patients for cog.-comm. because "we don't miss RUG numbers, here," as well as trained to use a RUG playbook in which ultra-high category was always sought after via penciling in therapy numbers, switching around numbers across therapy disciplines daily, only to finally trace over the final numbers with a pen to then submit for reimbursement, I now think a labor movement is in the works due to the naivety of owners and managers driving the productivity model thus abusing workers and ex-workers (the elderly) at the same time. It's not that difficult to organize. Check out the NRLB website for information on how you and your team can organize to collectively bargain for a better deal for you and your patients. In Solidarity, Sean
June 10, 2014
Susan Walters
Waiting almost a lifetime!
I am amazed that it took this long before ASHA finally heard the millions of SLP's out there! I personally had contacted ASHA on several occasions, written letters to ASHA, MEDICARE, MEDICAID and various State Agencies with regards to this style of healthcare with barely any consequences. It is appalling that the SLP's are still fighting this battle…for me personally I have had to leave several positions due to these pressures to perform illegally and unethically. It has been since 1979 and now when I am nearing retirement…ASHA write and article????? to tell us to "toughen up" really…ASHA does not have the political pull to influence this behavior really? All of the years paid in membership dues and we get a "toughen up" article! WOW!
June 10, 2014
Rachel Dozark Judisch
Pay reduction?
I see and work on both sides of this debate. Our focus is quality service provision, striving for that makes the numbers fall in line, but you must have the right staff for that philosophy to work which is difficult when there are many shortage areas for therapists. On one hand, therapists do not like "productivity" expectations, but on the other hand, therapists are asking top dollar salaries to work in the SNF setting. How does one manage this dynamic in a world of reducing reimbursement rates or rate increases that do not keep pace with inflation? I've debated giving staff the choice of 2 different pay rates when hiring, reflecting different productivity expectations. But then question whether the impression that practice would give.
June 10, 2014
Lisa Cole
Work smarter not harder and ADVOCATE!
I applaud the survey (and I completed it recently!) and the publicity on this topic. I have seen it from many sides, as a contractor, a therapist, and a rehab manager. A good manager will help you problem solve and work with you. Completing education, phone calls, documentation (and many of those "non billable" items on the list can be done with patients, family, team members present. Rehab techs, while dwindling, can provide assist with food and taking the patient to therapy. Transporting a patient is a therapeutic task if you communicate on targeted goals - memory, problem solving, visual spatial skills! Work smarter, not harder!! While this coordination and creativity can detract from 1:1 quality care, it does provide education and coordination of care which is critical to the patient's success. The rehab company and managers that DON'T support you, DON'T help you creatively problem solve are ones for whom you don't want to be employed. YOU Pick the company AND the managers that support you. NEVER accept a manager or company telling you that you HAVE to treat someone and it's unacceptable to have them make clinically inappropriate decisions for your care provision - not to mention unethical!!! Good companies, supportive managers are out there.... And if they are not.... consider a switch to a different environment or setting as a viable option.. We are in demand, and we deserve to be cultivated, appreciated, and supported!!.
June 11, 2014
Sarah Izzi
Let's get real
Having personally experienced pretty much everything outlined in this article, I think it's AWESOME people are at least talking about this very important and relevant issue. Look at that list of non-billable tasks... get real. No one would be able to accomplish what they're asking you to do, not given our patient populations (which often include lots and lots of folks who just don't feel like playing with you on any given day). So, enormous pressure from your boss, saying your poor productivity might get your corworker's hours cut, saying productivity is how we justify even hiring you... look at all the stuff you can't bill for... people are either working off the clock or billing for things you can't bill for or don't consistently make productivity goals. Period. End of story. But oh wait! We would also get in trouble for working off the clock. That's why I left!!
June 12, 2014
Marguerite Mullaney
ASHA's Responsibilities
While ASHA is not a union, it should have the same ethical obligations as individual members. Will ASHA continue to accept advertising money from companies under federal investigation for Medicare fraud? Will companies with 85% + productivity be allowed to participate in the vendor area of the ASHA Convention? Taking money from a company with unrealistic productivity demands placed on our members make ASHA complicit in continuing unbearable work situations which leave therapist trapped deciding between taking their paychecks or following the code of ethics. Taking money from companies which are accused of Medicare fraud and under investigation by the federal government exposes ASHA to claims that it accepted stolen money if the charges are proven. We as therapist must demand ASHA play by the same code of ethics we follow. We can not commit fraud for a paycheck, ASHA can not accept money from companies demanding therapists commit fraud. ASHA - it is time to ACT! The leadership needs to do just that - LEAD. Refuse to accept advertising dollars and vendor fees from companies which are gaming the system.
June 16, 2014
Coy Garrett
Working off the clock
One issue that raised my eyebrows was working off the clock, something that several SLPs referenced in the article. While that may not be a Medicare issue, it certainly is a labor law issue. If you are hourly and working off the clock, that is a serious violation of both federal labor law and the labor laws of most states. Further, if your supervisor is aware that you are working off the clock and does not take direct action to end that practice, then they and their company can become liable for serious fines and other penalties. The difference is whether you are salaried or hourly - if you are hourly then all your work for the company needs to be "on the clock". I realize this can put a SLP in a Catch-22 situation - but violating one set of (labor) laws to keep up with the documentation requirements of another set of laws and regs (Medicare) isn't the answer. I'd also like to add that there are companies out there who have reasonable guidelines and do enforce those guidelines in a reasonable way. It isn't just the number, and it isn't just the formula you use - it's whether you knee-jerk and cut hours the first day that productivity isn't perfect, or whether you invest in the time needed to build and maintain a good clinical program. It can be done - and thankfully it is done in quite a few companies out there today. I'm just sorry to hear of those who still face the wrong kind of pressure.
June 22, 2014
Sandra Sabonjian
My New Best Friend
I was so moved by Rachel Wynn's frustration. Not only are SLP's put under many unfair and unethical pressures, but we go from college into the clinical environment with almost no preparation or understanding of how things are run in a clinical environment. I've had so many experiences like Rachel's. When I first started my CFY, I was reprimanded twice for refusing to treat a dying patient. My supervisor wanted her to have a modified barium swallow study and insisted I take her down the hall for it. When I approached the Physician I discussed my concerns with him and he agreed. I took the patient back to her room and had the CNA put her to bed. My supervisor came in and began yelling at me in front of the patient. I ignored her and stayed by the patients side. The patient thanked me and dyed one hour later. That is only one of the many horrific experiences I had with that supervisor during my CFY. Eventually, and with my help, this unethical supervisor was fired. I vowed to either leave the field, or make a significant change in the industry. Moreover, when I first started in the field I had no idea how to write a Physicians Order, Daily Note or Care Plan and there was rarely anyone to ask, and no orther resources available to make documentation easier or clearer. I hated the way I was treated, but loved working with my patients. Everything was confusing and took 10 tens as long because I had no guidance. I decided to do something about that. I knew I would become a supervisor one day and make sure no one under me would ever experience what I went through. Soooooooo, over a period of a year, I wrote a manual for new SLP's called My New Best Friend. First released 2001. My New Best Friend has been used by my own staff for years and by hundreds of other SLP's. This year I updated it to reflect all the changes medicare has made. I named it My New Best Friend, because I first made it in notebook form for my staff and noticed that they were always "missing." I was actually honored that they wanted to keep the manual. It literally, became their new best friend. I knew I was onto something, so I self published it.. This book is available on my websiteL http://sandiegospeech.com/index.html.. I have been an SLP for the past 19 years and am proud I stuck it out. As a group we must stand up for patient's rights and do what is right for them and for SLP's. Our work is invaluable and critical in improving a patients' quality of life. If you chose this profession to get rich, well, you might want to rethink that thought, but like the majority of us, you probably chose it because you are a caring, loving person that wants to make a positive difference in someones life. Don't give up!
July 13, 2014
Carole Roberts-Wilson
Productivity in a nursing home
I was unaware of how widespread this issue is now. It has been an issue for many years. To be able to do the nest job it is difficult for me to reach the 90 per cent productivity. I applaud all that have responded. I think it needs to be changed or modified. I do know that there are therapists that committed fraud by working off the clock. I am proud of my facility where all the rehab. Staff gets respect and treat pele that need skilled therapy. We coordinate with ST, OT and PT and nursing and dietary and social services. We are a team and cannot do our job without these communications. I consider myself lucky to be working in my nursing home for close to 7 years.
January 21, 2015
Sue Garbin
Nothing Is Changing
I have worked in SNF's for approximately 18 years. Contract companies are sweeping in again (remember NOVACARE?) and demanding 90-100% productivity and pressuring SLP's who have lower caseloads (no control over admissions or rehab potential of new admissions) to "screen" and build up their Med B patients. This is clear-cut over-utilization. I have spent most of my career refusing to A) See patients who don't benefit/need services. The comments that SLP's are "forced" to do this is partly true, but mostly, it's a choice based on economic blackmail--do it or be replaced by someone who will. B) Use my time to do paper work. They don't call it paper "fun." If we give away our services, we set a precedent C) Inflate minutes for the purpose of "hitting" a payment category. It galls and offends me that administrators would not ask me to steal a patient's wallet but they will ask me to "pick" the insurance companies pocket and be indignant if I refuse. I am angry and tired of the fact that ASHA does nothing to change this. What are my dues really paying for? I am frustrated with other therapists who cave in to these illegal demands. I understand the need for a job, but as a DOH surveyor once told me, "Overutilization and abuse starts with the therapist. If no therapist was ever willing to cross the line and justify this type of practice, there would be nothing the SNF's could do about it." The trouble is, there are always therapists who will do whatever is asked because they fear unemployment or confrontation. They put their heads down and add those extra five minutes because they know it's very difficult to prove abuse (unlike fraud). I am currently looking for other avenues to make money because I won't do what is asked. It makes me ill that I've spent my adult life and a lot of money (yeah, they don't respect us enough to buy materials or even give us a desk at which we may treat patients) in this field. We've had a million man march and now it's time for a million therapist march. We need to take back our professions and stop letting greedy, corrupt contract companies and for-profit agencies tell us how to do our jobs. I guarantee every therapist on this site that if you make the wrong choice in order to stay in an employer's good graces and you are found out, they will never stand behind you. They will toss you under the bus in short order. My new challenge is with dietitians who now expect me to evaluate residents with zero dysphagia but no teeth for diet upgrades. It's a new way to turf responsibility if they choke on the regular consistency and suck money out of insurance for a nonmedical issue. All staff are colluding now in this game of squeezing insurance. Most of the grief I get comes from the MDS coordinators who come to me and tell me that I need to get X minutes with Mr. Jones or "we're going to lose so much money and ______ will be furious!" This is employee abuse, coercion and pressure to perform illegal acts. How did it get this way? Why are so many therapists willing to tolerate this. I am so sorry for the rant, but I am at the end of my professional tether. My last really good facility was just taken over by yet another contract company (Health Pro) and the directives have already been made. We must reapply for our jobs, make less money, work more hours and be sent home if our caseloads are not maxed out. Further, we must must (must!) increase Medicare part B utilization. This is clearly unethical. How in the world is this legal? Why is no one suing these companies? Elders are being held hostage in some facilities under the guise of "unsafe discharge" because they still have 20 days left from their Part A benefit. I'm sorry...but I am ready to give up.
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June 2014
Volume 19, Issue 6