You can survive under PPS, AZ facility says

SNF impact shows sign of things to come

Like many rehab administrators in skilled nursing facilities (SNFs), Pat Moorhead can divide her tenure at Scottsdale (AZ) Healthcare in two: before and after the prospective payment system (PPS) was implemented. The message she gave to administrators at the 2nd annual PPS for Rehabil itation Conference in Atlanta in April was this: You can survive, but be prepared to decrease therapy costs and manage them much more aggressively.

Moorhead, who recently served as manager of rehabilitation services for Scottsdale Healthcare, characterizes life under PPS in these ways:

  • Many patients are being shifted from the SNF to the hospital rehab unit. In mid-November, Scottsdale Healthcare closed 30 SNF beds in the unit because of this shift. The rehab unit is now operating at 16 beds rather than the 10 for which it originally budgeted.

  • The unit uses more staff therapists and few, if any, contract therapists or on-call employees. In Phoenix, a heavily capitated market with a large Medicare managed care population, the job market for therapists is tight, Moorhead says. "No one is leaving. Many places are having layoffs. There is nowhere else to go in the Phoenix area at this point, so therapists who might have left before if they weren’t happy are staying." As a result, few have scoffed at working later hours — a necessity because most admissions don’t arrive until at least 3 p.m., and evaluations must be done on the day of admissions to capture the minutes of care needed for reimbursement. Also, nurses and therapists are more open to working weekends, and the same therapists are working each weekend, which improves continuity of care, she says. The facility also cut its recreational therapist staff position.

  • Staff have had to increase efficiency. "We used to have a standard of 22 patient care units per day, and now we have an average of 24 to 26," she says. "We also are encouraging therapists to deliver care in group settings, and those therapists are averaging 26 to 28 patient care units a day." Again, the tight job market has made therapists more willing to increase their workloads.

  • Time is built into some staff therapists’ schedule to do MDS data entry. Scottsdale Rehab has designated one senior therapist for the role, and time is built into that therapist’s schedule for those duties.

  • Interaction among nurses, physicians, and other staff members has increased. There is daily communication with nursing staff on patient progress and regular communication with case managers on discharge plans. Staff also make daily patient rounds with the physicians and use those interactions to suggest changes that might increase efficiency (such as switching antibiotics or changing dressings). Finally, staff have developed discharge criteria for each category of care.

    Moorhead offers the following survival tips for providers:

    Know your rates and your payer mix. Compare these rates to your cost of care and evaluate potential new contracts carefully.

    Question every cost, beginning with supply costs. Supply costs are a great way to save money, Moorhead says. She has educated staff nurses about the expense of hospital supplies and services, and she plans to set up a display during Nurse Week that includes costs for linens, cathe ters, and every other supply used in a patient’s room. This causes nurses to think twice before automatically doing things. Actions that can seem small on the surface — such as using towels instead of sheets in some instances — add up to large savings in the course of a year.

    Look at managing care across the continuum. Scottsdale Rehab uses weekly team meetings to evaluate where in the continuum of care a patient can be served best, Moorhead says. "If a patient still meets the criteria for the acute care unit, we’ll keep them there rather than transferring them [to rehab or the SNF]."