If you can’t beat them… Start your own rehab company

By April 29, 2014 Ethics 15 Comments

SNF Ethics

Thanks so much to Janet for sharing her journey and passion for improving elder care on the blog today. Support her big risk of starting her own rehab company and get in touch with her if you are in the Massachusetts area.

I’ve heard about defining moments in a person’s life, but I never imagined I would experience one. But I did. Almost three years ago. Since then I’ve committed my heart and soul to making a difference, but, not just in the lives of my patients but in the lives of the therapists who serve them.

Driving Force
My a-ha moment came one afternoon while I was working as a rehab manager in a SNF. A month earlier, a right MCA CVA patient was admitted for short term rehab. Upon admission he had no functional use of his left upper extremity, left lower extremity, severe dysphagia, and a g-tube. The patient and family desperately wanted him home despite the severity of the CVA. All three disciplines began working intensely with him and by the end of that first month, he’d made unbelievable progress. He was able to brush his teeth, walk with assistance, and successfully tolerate small portions of puree with no signs of aspiration. The patient was thrilled, the family was thrilled, and a meeting was scheduled to discuss early discharge preparations. Then, I got a phone call from my boss.
“I was looking at your planner in SMART and I saw that you were way over on the minutes for Smith.”
“I know.”
“Well, what are you going to do about it? Your gonna miss your margin.”
“I know, but he’s very involved. And he’s making fabulous progress. He’s even tolerating puree and speech firmly believes he will get off that g-tube. He’s starting to walk and feed himself.”
“Those minutes need to be cut.”
“But if I cut down on the minutes, he’ll lose ground.”
“Well, you’re gonna need to have a discussion with his family about limiting the minutes. And ask him to choose the most important therapy to him.”

There was dead silence. Most important? I have to ask this man to choose between eating, walking, and feeding himself? And I have to tell the family about a fictitious limit on minutes because the added therapy time was eating into the company’s profit margin? I hung up the phone and hung my head.

Then I did something of which I’m not proud. I went to the family meeting and explained the “limit” on minutes and that we needed to cut back on their father’s and husband’s rehab time. Oh, I must have explained the fictitious minute limit very well because after the meeting the family was thanking me. Thanking me? I felt sick. What had I become?

The following Sunday morning, I woke up and said to my husband, “How do you initiate change?” Armed with only my vision of what I thought was right, I started a Facebook page. SNF Rehab Therapists for Change (SNFRTC), now American Association of Rehabilitation Therapists (AART), was born from my frustration, disappointment, and quite frankly fear of the direction rehab was going in the SNF environment. I dedicated the page to the SNF therapists whose daily work offered frequent moral and ethical challenges because of an industry that soullessly placed revenue generation demands above patient’s actual needs.

I began a letter writing campaign to every presidential candidate, every local and state representative in the New England area, and every New England state’s senator. I called the Boston Globe, the Wall Street Journal, Healthcare Finance News, Channel 5 news, Channel 7 news, the APTA, the AOTA, ASHA, the APTA lobbyist, President Obama, the National Nurses Union, the AFL-CIO, and even Occupy Wall Street. What I got back was a few form letters thanking me for my concerns and a call from my representative’s office telling me they didn’t know what to recommend.

Slowly, over time as the Facebook page grew and therapists all over the country joined in the discussion, I began to understand that a page to post reactions and lend support, although immensely helpful, wouldn’t attain industry change. The page provided the ingredients, but it needed a catalyst.

On December 5th, 2013 my catalyst, Arete Rehabilitation, was born. The old saying of, if you can’t beat them, join them? I changed to, if you can’t beat them, join them and then beat them. What if I could start a rehab company and take away the incentives to push minutes? What if I could offer therapists a work environment that valued their clinical decision making and respected them as professionals? What if I could offer SNF’s quality rehab services, do what’s right for the patient, treat therapists with the professional respect they deserve and still make money? So that’s what I did.

Arete offers therapists salaried positions or guaranteed hours with no productivity requirements and an expectation to teach and train the facility staff and participate in company paid lifelong learning. This allow SNFs to be charged a flat, fixed monthly rate that doesn’t change based upon RUGs levels or by a high Med B caseload. The therapists can attend meetings, assist in marketing, and speak to family and other team members, without the constant productivity worry. It’s by combining these two critical components that Arete promotes quality, ethical, and cost effective treatment. By focusing on what each patient needs, the financials will follow.

Will the big companies stand up and notice? Will they ignore me and assume one PT in Massachusetts couldn’t possibly affect change across an entire industry? I hope so because the one thing I’ve discovered…I like being the underdog.

Guest blogger bio
Dr. Janet Mahoney is a physical therapist who advises her colleagues and customers on how to provide quality rehabilitation services in skilled nursing facilities. She established the grassroots organization, American Association of Rehabilitation Therapists, in 2011 which supports therapists who struggle to maintain ethical patient care practices in skilled nursing facilities. Prior to that time, she spent 20 years in skilled nursing rehabilitation management and in 2013 established Arete Rehabilitation, a contract rehabilitation services company which offers SNF’s and therapists a unique choice.

Dr. Mahoney attended Simmons College in Boston, MA where she graduated with a BS in physical therapy. She recently received her doctorate in physical therapy from A. T. Still University in Mesa, AZ. In her spare time, she loves to read and write mystery novels, walking along the New Hampshire shore, and spending time with her family. She currently lives in Amesbury, MA with her husband, three children, and three dogs.

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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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  • http://www.bethanyriebock.com Bethany

    Congrats, Janet, on making such a courageous move! Around the same time that you opened Arete, I left my “career” as a director of rehab in SNF after almost five years of tenure at a few different organizations/companies.

    I’ve seen salaried therapists converted to hourly, who were then expected to crank out minutes and maintain anywhere from 85-100% productivity on a daily basis. Don’t get me started on the 100% expectation…

    I’m very curious to learn more about how you’re able to successfully manage hitting RUG levels and managing under- or over-utilization, as you touched upon earlier in your post. I would imagine that “setting free” the therapists could lead to missing RUGs by 5-10 minutes and/or providing 800+ minutes to the medically complex & highly involved CVAs.

    • Janet Mahoney

      Thank you for your kind words. So many qualified therapists are leaving the skilled nursing environment because of the productivity issue and many other challenges. The answer to your question about RUGs levels isn’t a popular one but here goes: Each RUG level isn’t really a level, but, a range. For example: Rehab High ranges between 326 and 499, Very High between 500 and 719, and Ultra from 720 to the sky’s the limit. These “levels” were never meant to be restricted to certain sentinel numbers, like; 325, 500, and 720. They were designed to be ranges to accommodate for the varying tolerance patients demonstrate on the road to recovery. This allows therapists to adjust their treatments accordingly. However, these ranges morphed into limits (not by Medicare, but by those who bill Medicare), and became the standard, instead of the exception. So what, if a patient hits 719 on day 8? If they can tolerate that amount of therapy, their next ARD will be at the almighty 720 AND a COT can be performed to get back those 7 previous days at an Ultra level! The system is designed to provide each patient what they need, based upon their individual needs- not the needs of the stockholders.

  • Lisa

    Wow! I’m very impressed with what you’ve done! I’m also very interested in learning how you’ve achieved this. Any chance you’ll expand into Connecticut?

    • Janet Mahoney

      I’m definitely interested in moving into Connecticut. Let me know of any buildings that are unhappy with their current provider and I’ll be grateful and happy to contact them.

  • Rosemarie

    Good for you Janet! It is very exciting to see someone finally take rehabilitation services in snfs in a different direction. I am an SLP in Ohio, and have worked in SNFs for the majority of my 16+ years in the field. I am constantly appalled at the unethical direction that the rehab industry has taken since the advent of PPS, including misinformation and manipulation of therapy staff. We who toil in this difficult environment are challenged on a daily basis to keep our therapeutic interventions patient- focused and appropriate for their functional gains. I have begun to transition to hospital- based patient care which seemingly have more flexible productivity demands and patient- appropriate interventions. I hope that you will succeed in your business endeavors, and change the professions for the better.

  • Ryan Liebig

    Such a great article and inspiration. I too feel I’ve been in your shoes. I too want to make a change. As a recent AT Still graduate with 1.5 years experience, I do get discouraged the way corporations are driven only by money. I feel as if they place little value on my clinical expertise and only care about the bottom line. I don’t have all the answers nor do I claim to know what’s best but I do know change is needed and I hope I can be a part of a much needed change.

    • http://www.graymattertherapy.com Rachel Wynn

      Ryan- Don’t let being a recent graduate deter you from making change. I haven’t hit the 3-year mark (graduating in August 2011). You can be a part of the change!

    • Janet Mahoney

      I’m a graduate of A.T. Still University as well- in the DPT program. They are very supportive of the “right thing” to do. Congratulations on your graduation and don’t get discouraged. This is a process from which good things will eventually come and you’ll be part of it.

  • Pingback: What's next in SNF ethics advocacy? - Gray Matter Therapy()

  • Diana

    Glad to hear of your endeavors and I will be happy to follow your progress. I left my job also related to having to enforce the productivity rules in a SNF. There is a better business model. Are you making money with your method?


    • Janet Mahoney

      Yes. The margins are slimmer than the big “box” rehab companies, but, that’s because I believe that a successful business is a result of the employees that do the work. I would rather make less money personally and invest in my employees. After all, I’m not going to be the one treating the patients in the buildings- you are.

      I just saw a great quote:
      You don’t build a business
      You build people
      And then the people
      Build the business

      Thank you for your comments!

  • Jessica Hayes

    Dr. Mahoney, I am a recent PTA grad in Ohio. I currently work for an inpatient rehab center who does not have a productivity requirement and a SNF that has a 90% requirement.
    I have been tossing around the idea of opening my own rehab/SNF setting for quite some time and seeing the difference in care between these two facilities has fulled my passion even more.
    I tried to access you companies website, but it’s down for maintenance. What exactly is your company? Do you provide therapy services for current SNF or rehab centers?
    I’m trying to find a general direction and I’m not even sure where to begin.

  • Lisa

    Such an inspiring story! I must admit that as a new therapist, I am already finding the productivity expectations in conflict with patient care to be quite disheartening. So glad there you are out there, being the change you want to see in the world! Gives me hope

  • AnnMarie

    Hello, so glad and interesting that I came across this. I am frustrated to death with these rehabs! For three years I’ve been dealing with them as a family member is the patient and I am sick of it. Furthermore, WHO exactly is overlooking these facilities to ensure they comply with their moral obligation to treat these amazing human beings with the degnity and respect they deserve!? SO, I have been looking to start my own skilled rehab center in the Bay Area. But since I haven’t done anything like this before (starting a rehab) I need help. If anyone can direct me towards the right path I would appreciate it! I guess my main concern is funding. Thank you, AnnMarie

  • Keith Blake

    Hello to all, being a recent PTA grad and working in TN at a SNF has sparked my interest to look at opening up a company of my own, one that believes in and stands behind their therapist. The company I work for does not offer raises, promised me full time hours and am lucky to work 25 hrs a week, and didn’t allow me to negotiate pay being a new grad. I want to build a company that invest in their therapists’ and possibly open up a SNF eventually after seeing the care my pt’s receive form the CNA staff. Any info you could provide to me about your endeavor or point me in the right direction would be greatly be appreciated, Thanks, KB.