Ethical Considerations – May 2014

By May 5, 2014 Ethics 14 Comments

SNF Ethics, SLP

Ethical Considerations is a monthly series looking at ethics in elder care and therapy. Often ethics are talked about in hushed voices; however, ethical concerns are something worth speaking about. This series (occurring on the first Tuesday of each month) will update you on what is new in advocacy and offer recommendations for getting involved.

Managing the transition from volume to value: Productivity standards

I attended the “Managing the transition from volume to value: Productivity standards” webinar (April 2014) offered through the American Physical Therapy Association’s Learning Center. With my interest in SNF ethics and the current involvement of ASHA, AOTA, and APTA in addressing our concerns with SNF ethics, I expected different content in this webinar, but there was still some worthwhile information. Unfortunately only 8% of the attendees registered as SNF therapists, so I wasn’t the target audience. The webinar was led by two physical therapists. James Dunleavy spoke about the actions of the APTA Acute Care Section of the Productivity Task Force. Lynn Steffes spoke about changing the definition of value in the private practice setting, an inspirational webinar for private practice owners. I will focus on James Dunleavy’s section regarding acute care therapy for this month’s Ethical Considerations.

Dunleavy started the webinar with an example of “really good” productivity where services were provided in the highest quantity and fastest/efficient as possible, but in the end the patient dies. While this would be considered good productivity, it doesn’t consider patient outcomes at all. Dunleavy proposed changing our language and redefining the value therapists provide in the acute care setting.

“We have to blow up our perspective of productivity in acute care environments. We need to look at the healthcare system in new ways. We need to find points in the system that we can make a difference. And bring the concept of value and new definitions to the professional approach to this issue.” – James Dunleavy

I agree. Our language needs to change. Productivity has become a four letter word, meaning little to patient outcomes and much to company’s bottom lines. Both speakers in the webinar argued for a perspective of value generating care rather than revenue generating care, especially in the acute care setting where the Medicare payment structure doesn’t pay extra for services like therapy.

Dunleavy quotes Michael Porter’s article “What is value in healthcare?” from the New England Journal of Medicine (12/23/2010):
“Value should always be defined around the customer, and in a well-functioning health care system, the creation of value for patients should determine the rewards for all other actors in the system. Since value depends on results, not inputs, value in health care is measured by the outcomes achieved, not the volume of services delivered, and shifting focus from volume to value is a central challenge. Nor is value measured by the process of care used; process management and improvement are important tactics but not substitutes for measuring outcomes and costs.”

The Acute Care Section of the APTA Productivity Task Force has been working on a variety of goals including developing a new paradigm of acute care value measurement, creating a position statement on productivity in acute care, identifying the value of therapists within the health care system, and creating a tool that “integrates cost of service, patient severity, intensity of services, and patient outcome measures that produce a measurement of value to service to patients, facility, and healthcare system.”

The tool being developed by the APTA Productivity Task Force will help determine which patients we provide the greatest value to, which patients gain little from our services, and determine prognosis for patient function.

I would also like to note, I paid $99 to participate in this webinar, because I felt this was important information to share within the therapy community as we work together to improve elder care. I believe this information should be shared by APTA, AOTA, and ASHA with members as a part of our membership fee. After all, they are reporting on what associations are doing (with our member fees) for our professions.

Medicare Guidance for SLP Services in Skilled Nursing Facilities

If you haven’t had an opportunity to check out the resources that ASHA has been adding to the website, make sure you check out the Medicare Guidance for SLP Services in Skilled Nursing Facilities. This is the type of information I asked for when I met with ASHA staff members and board of directors at the members forum at the 2013 convention.

I encourage you to use this information as talking points with your employers to advocate for elder care. It is also a great resource for clinicians who don’t understand Medicare’s Prospective Payment System for part A benefits. At the beginning of the document ASHA writes:

“Medicare guidance for Part A services is found in the Resident Assessment Instrument (RAI) Version 3.0 Manual. The manual provides specific direction about therapy services in Chapter 3, Section O. Even when institutional policies are based on Medicare guidelines, the interpretation and implementation can differ from facility to facility or manager to manager. SLPs should become familiar with the manual rather than relying on interpretations from others.

I know, I know. That’s the kind of thing that drives many of you crazy. We’re looking to ASHA for answers and ASHA tells us we’re responsible for familiarity with the manual “rather than relying on interpretations from others”. Are they just passing the onus onto us when we’ve asked for help? But let’s put managers, directors, corporate, etc. in the place of “others”. Now it makes sense, right?

And I agree with ASHA. We need to know Medicare guidelines and interpret them in a way that honors our practice and patients. Does anyone know of a good study guide or walk through to accompany reading the Medicare guidelines? Should I create one for you? I would love to hear your feedback before I get started on a guide.

Those who watch a spectacle share in the guilt of those who create it

I stumbled upon this post and knew I had to include it in this month’s Ethical Considerations. I must warn you. The introduction is beyond words. Disturbing is my best attempt. Some topics are hard to deal with, but read through to the end. It’s worth it. (Go ahead and read it then come back.)

Several things struck me. First, it made me question my inclination to donate my body to science. Second, when in doctoring/healthcare professions do we separate ourselves so much from our patients that we allow these types of things to happen? Third, are those that watch the spectacle of Medicare Fraud/Abuse and poor elder care share in the guilt of those who create it? In my personal experience the answer is yes. The guilt I felt working with some teams made me sick. When I found out that the administrators at one building celebrated when a patient reached 100 days under Medicare part A (therefore maximizing reimbursement from that patient), I felt sick to my stomach.

Stay tuned for the rest of the month as we discuss death and dying on the blog. A month focused to death and dying has been on my publication calendar for months and as it approached I found so many podcasts, articles, videos, etc. to really help us dive into this difficult topic.

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Rachel Wynn
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Rachel Wynn

Speech-Language Pathologist at Gray Matter Therapy
Rachel is a speech-language pathologist and creator of Gray Matter Therapy. She started making noise as a patient-centered care advocate in 2013. She believes great care happens when patients are informed and engaged.
Rachel Wynn
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  • Julie Maples

    Interesting blog post, Rachel. I hope the webinar will be the beginning of a move in the direction of returning the focus of therapy to what the patient needs, vs what the company needs. Certainly, we cannot be blind to the fact that we work in a business, but patient care and needs must be the focus. The idea of managing treatment minutes based on achieving a predetermined level, seems to fly in the face of doing what is best for any given human being on any given day.
    I think managing treatment levels, ties in with the cadaver story as both serve to dehumanize. Certainly we have to step back at some level, to keep from taking all our work home. But we must first and foremost remember that in a SNF, we are dealing with our most frail elderly, who deserve our respect and the benefits of our particular skills.
    To best serve our clients, we must continue this conversation. Thank you for helping to lead the discussion.

    • Rachel Wynn

      Thanks for your comment Julie. I really hope these conversations will continue and action will result.

  • Karla Jo Grimmett

    I’ve also worked in acute care and can tell you that while patient care was stressed the thing that mattered most was our productivity level. It came down to how many units a day we were able to bill the hospital population.What productivity robs the very facilities we work in is our expertise in helping staff, in teaching each other and robs the patient of dignity at times because we have to focus on what’s billable, not what’s humane. Its a crazy way to administer “care” and it needs to be redefined to actually include what is the best outcome for those we serve and those we work with.

    • Rachel Wynn

      Thanks for your comment KJ. I would love the work I do to be measured by outcomes! I’m a damn good therapist.

  • Jan Bird

    I have been forced to start educating my DOR, Area managers and area VPs about the RAI guidelines, following a retaliatory write up supposedly for low productivity, 82.7% instead of 85%…(which was actually a retaliatory move to punish me for distributing an ASHA Leader article addressing productivity). It continues to be challenging and I continue spreading the word and, thankfully, we have email to distribute materials. Having been written up for giving my colleagues the article I was ordered to NOT hand out any “unapproved” items and I refused to sign or agree. It was the next day I was written up and during the process told that I need to bill for evaluation time taken ‘away’ from the patient and other “non-billable” activities. This was reported to HR and the ‘writeup’ withdrawn. My colleagues continue to be challenged, as do I, with continued productivity pressures. We are forced to achieve 85% or be ridiculed. Many, including myself will work OFF the clock in order to achieve that goal. My only hope is that Skilled Nursing Facilities will see their way clear to put therapy ‘In House’ where the little monies for profit is no longer pirated by the contract rehab companies.

    • Rachel Wynn

      Jan- I am so sorry you are dealing with this awful situation. I have been written up or put on an “improvement plan” twice due to productivity. I would recommend that you document the heck out of everything that is happening.

      I love my in-house therapy team! Now that I’ve worked for a therapy team that was supported by administration, I want to see it happen everywhere. Check out the other success stories and what we’re doing to support change here.

      • Karla Jo Grimmett

        Jan and Rachel, I wonder what would happen if all those hours worked off the clock because corporate demands them, but refuses to pay for them were turned in to the United States Dept of Labor from all therapists across the nation at ONE time. What corporate wants to do is treat us all like Independent contractors, yet have the control of employer. When we sit down and figure out what our actual hourly rate is when we give away time to these companies, it can be very sobering. Do we really want to diminish our value by giving away time doing something that is demanded by medicare and our employers? I don’t think so.

        • Rachel Wynn

          I couldn’t agree more. We need to focus on helping people see the value we can provide.

  • Anonymous

    I am only remaining anonymous for fear that someone in my company may read my comments and it would affect my job. I am in a SNF and my employer requires 90% productivity. That leaves me 48 nonbillable minutes in an 8hr day to perform all possible job duties that can not be done with the patient. At least 10-15 of those 48 minutes are used in nonbillable transport (getting to their rooms). Other minutes are used filing orders, searching for charts, telling nurses of diet recommendations, schedule recovery, and occasionally going to the bathroom. I am expected to do everything within the patient’s session (even tasks that aren’t for THAT specific patient , i.e. a discharge report for a patient who was admitted to the hospital). I have often explained that SLPs have a harder time completing job responsibilities compared to PT/OT because we can’t set up a patient on a piece of equipment for 15 minutes and go do other clerical tasks. I was actually told once “If you increased your session length you would have timem to do some of those things”, and “If you picked up more cognitive patients there would be paperwork you could set them up with”. The only way PT/OT meet their productivity is that they clock -out saying they have “taken full meal break”, but none of them sit down and take the 30 minute lunch . They snack or eat for 10-15 minutes then use that leftover time as a buffer, so they really do work off the clock.
    I am CONSTANTLY pushed to evaluate and treat patients that have no business needing Speech Therapy. My employer uses clever terms to try to convince me (and convince themselves) that therapy is justified. They get upset when my clinical judgement does not match their plan to obtain an Ultra RUG category by including Speech Therapy minutes (usually to make up for the minutes PT/OT can not obtain because patient can’t participate, or won’t). If I recommend a 30 minute treatment based on patient need, my DOR will increase the minutes to 45 or 50 without my approval, solely to meet a RUG. My DOR also asks why I don’t recommend 30 day treatment plans for all my patients. When I explain that I may only do a trial because I feel the patient is not likely to benefit, not all patients NEED 30 days, or it does not take 30 days to downgrade a diet on a patient who is not capable of advancing, I’ve been given the response “We’ve never gotten a denial before”.
    I have been pushed beyond my ethical limits, but when discussing it with regional representatives, it was ME who was treated like the wrong-doer. It’s ME (who has 20 years of clinical experience from ICU to the outpatient level) who gets told to talk to other SLPs in other buildings to get “ideas” for therapy when I don’t think a patient would benefit. It’s not that I don’t know what to do for the patient, it’s that I don’t feel there is anything I CAN do to foster improvement, or there hasn’t been a decline or change to justify treatment. I can’t treat a patient who scores WNL on two sets of standardized tests either (and yes, I’ve been asked to treat patients who score WNL. “Can’t you teach them life skills? I hear her house was a mess”, were the words of my DOR). I have ALWAYS been challenged when failing to recommend therapy for a Medicare A patient, but I NEVER get challenged for a Medicaid or Med B patient. No one cares about them. Only those that are “skilled” are pushed to be seen.
    These are the things I deal with on a daily basis. It’s sad, frustrating, stressful, and insulting. Not once has my DOR provided a positive comment about the outcomes I achieve with my patients, or my documentation that exceeds standards of many that I’ve seen. Not once has she commented about every single step I took to try to be as efficientt as possible , including buying my own therapy cart and streamlining it by having all the materials I need with me as I run around the facility like a slave.
    I’ve been to other buildings within the company, and I see how the other therapists “play the game”. It’s evident in their treatment plans. They all have the same goals and do the same exact thing with almost every patients. They use the canned goals in the computer, and not once have I seen an individualized goal that is creative. They pretty much see every patient admitted, regardless of their prior level of function or prognosis for realistic improvement. I have never been so discouraged, disgusted, and disappointed in the direction of the therapy world. It IS fraudulent. It IS unethical. It is NOT what I went to college to learn how to do. It is NOT how I should be treated at my level of expertise and clinical skill.

    FYI, I have worked for Genesis Rehab in the past. Their productivity expectation was 85% (2-3 years ago). I worked for a hospital, and they are just implementing productivity standards now (80%). Even as a manager who worked 10 hours in the facility and at least 2-3 more at home (only on management tasks) I was expected to be 50% productive with patient care.
    The hospital setting is quite different. There is no push to see specific patients. You see who needs treatment. You decide how much, how long, and you don’t worry about anyone questioning your clinical judgement. You would never keep a patient with a treatable UTI in the facility for 100 days (unlike the SNFs). You would never be referrred to treat a patient for “memory deficits” because they forget to lock the brakes on their wheelchair, despite the fact that they may have never used one before in their life and aren’t familiar with them.
    I could go on and on. I apologize for the rant, and appreciate the forum to vent. I just really want people to know the reality of what is actually going on out there. These are not made up stories or exaggerations. This is not someone holding a grudge for any reason. This is exactly what I live with during every working hour and billable (or nonbillable) minute of the day.
    Sadly my patients do NOT get the quality care that I know I can provide. I can not spend time communicating with families or training staff like I should. I do not have access to the tests and materials necessary to provide good service. I do everything that is expected of me, run like mad, wear myself down, and feel burn-out every day. What does my company do to support me?……..nothing, they just keep asking for more.

    • Rachel Wynn

      Thanks so much for sharing. This story of burn out is all to common. Being a rehab therapist and working with elders is awesome! This is just the beginning to change rehab therapy.

  • Rachel

    There is a big elephant in the room that is not being addressed in the productivity blog posts and comments. I see and work on both sides of this debate. Our focus is quality service provision, individualized to patient needs, 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. This generalized demonizing of “working in SNFs or contract rehab” is not helping improve the staffing challenges or quality of care to patients.

    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.

    What solutions do you propose that can work within the current system structure?

    • Rachel Wynn

      Rachel –

      I can tell you care and this whole situation is frustrating to you also. We’re all suffering from some growing pains right now. As a community we’re starting to talk about the issues. My advocacy was started as a way to create conversations that would validate concerns (that some but not all therapists were having) and ultimately lead to conversations that would improve elder care. Now we’re trying to figure out exactly what to do about these concerns. I hope we can work together to affect change.

      You bring up a good point. Dollars only extend so far. In my personal experience, I took a substantial pay cut to work at a building that gave me clinical autonomy and had lower productivity requirements, which allowed time to do important non-billable tasks such as consulting with social work, nurses, other therapists, family members, prepare for therapy, review charts, etc. I would propose stating a productivity expectation that allows clinicians time to complete important non-billable tasks to improve patient outcomes and offering an hourly rate according to the value the therapists will bring to the patients you serve and your company.

      As far as therapy shortages, I get so many emails and comments from therapists that gave up. They burned out after a few years. I love working with elders. My blog started as a way to share this love with other therapists. My advocacy started as a way to improve the setting that so many people were leaving. I was really close to leaving too, after just 2 years. Then I found a company that was empowering their employees to provide great elder care. I want to see more those companies. I want to see therapists excited about working in this field. It is my hope that as we improve the work environments and elder care we can reduce the shortage. We’ll create jobs that people don’t want to leave.

      In regards to the right staff, I would love to see graduate programs offer more education in the area of geriatrics. (Though I have not done extensive research on what is or isn’t being offered. I only know what clinicians have casually reported.) I am working on providing continuing education via the blog, webinars, and public speaking to help therapists improve their craft. I want to see quality of services delivered improve too. Quality improvement was my original goal of starting this website and it still remains a priority. It’s the only reason I started Research Tuesday.

      If you have time, I would love to have a more extensive conversation over the phone. I want to see elder care improve, and we can’t improve it without the participation of awesome rehab companies.

      • Laura

        I feel the pressure of 87% productivity average (this month I’m at 84% and my dot will have to justify it to regional manager Monday) and point of contact service on iPad constantly, for all documentation. Big yells for backing up time to enter a patient. So, if I forget and leave my iPad in office to go see someone, I’d better run back to get it because corporate tracks our time stamps which MUST average less than 15 minutes point of service. This is a bigger pain in the *** than you care to imagine. We hear about it constantly. Oh, heaven forbid anyone’s time overlap by 1 minute with a patient. You’d both better have a cotreat note! All this, to make us appear more honest! It’s a crazy system! And we are told we are the only building having trouble with it! We all know other therapists that work for the same company that hate it too! At the end of the day we have to sync out. Before we do we have to press an agree or disagree button stating we accurately represented all our time. Sometimes, I have notes to finish (which I am told I should be doing at point of service) at the end of the day. My productivity looks horrible, so I clock out 30 or 45 minutes earlier, but corporate can clearly see (all entries are time stamped) and I think they could use this info against me or others who do the same. The expectations are crazy! At least I’m never forced into picking people up or seeing people who are too ill or absolutely refuse! I strongly suggest others stand up for their clinical decision making skills!

  • meemoo752

    Hello Rachel,
    I am a nurse educator. I teach orientation classes to newly hire RNs and PtCAs (Patient Care Assistants) in a hospital in Pennsylvania, however I work for the health sciences college associated with the hospital. Since I began working in my role, the term “non-productive time” has surfaced more than a few times, and quite frankly I am beginning to dislike it immensely, maybe even hate it- for a number of reasons. I keep hearing from clinical educators about the incredibly high infection and falls rate the hospital is experiencing among its patient population and wonder if this “non-productive time” attitude might be a contributing factor. The term “healthcare industry” has contributed to this attitude as well, I’m afraid. It’s become about the bottom line and who is profiting from healthcare, not patients. It’s become about the task- all the stuff that needs doing.
    How does this go away? Well, in my humble opinion, I think the focus needs to be on the patient and all that surrounds the care we provide. “That” meaning education, relationships, time….all the stuff floating around out in the gray cloud that is a part of caring for people. There is no black and white. It’s all shadows and light. It’s that vague ambiguous thing we call empathy or human connection that makes what we do as healthcare workers improve outcomes. When the term “non-productive time” goes away things will get better.