Home Health Care SLPs in SNFs Share Stories of PDPM-Related Layoffs, Treatment and Pay Cuts

SLPs in SNFs Share Stories of PDPM-Related Layoffs, Treatment and Pay Cuts

by Bridget Murray Law
written by
hands cutting the word "JOBS" printed on a piece of white paper with a blue background.

Last Saturday, speech-language pathologist Summer Branch went to work as usual at the two skilled nursing facilities (SNFs) she traversed. Both West Texas facilities contract with a larger rehabilitation company, and Branch was surprised to get a call from the company’s regional manager when she clocked out of work that day.

The manager told her that, as of that minute, the job she’d had for four years was terminated due to staffing changes. “I just didn’t see it coming,” Branch says.

Suddenly, she no longer had health insurance. But, if she wanted, she could opt for pro re nata (PRN) employment, in which the company would hire her to work as needed. Branch rejected that option because the company would pay her the same hourly wage without providing benefits or paid time off. (Typically PRN offers a significantly higher hourly wage to offset the lack of benefits and leave pay. Not in this case.)

Several states to the east, in Georgia, another SLP (who asked that her name not be used) experienced a similar shock. Her two-year job in a SNF contracted with a large rehabilitation company came to an abrupt end Monday. They had given her only two weeks’ notice. The company refused to pay out the entire 80 hours of leave she’d accrued and hasn’t sent her an official termination letter despite her requests. That’s made it impossible for her to claim unemployment.

These two SLPs  aren’t alone in losing their SNF employment. In the past week, SLPs, occupational therapists (OTs), physical therapists (PTs), and OT and PT assistants in SNFs have experienced a seismic wave of layoffs, pay cuts, and reductions in hours as the skilled nursing industry reacts to Medicare’s shift to the Patient Driven Payment Model (PDPM) Oct. 1. These effects are noted in news reports, messages sent to ASHA, and social media postings. ASHA is working with the Centers for Medicare and Medicaid Services (CMS), rehabilitation providers, SNFs, and industry organizations to address these effects.

Therapist cuts

PDPM replaces the former Resource Utilization Group, or RUG, model of Medicare reimbursement, basing payment for services on a patient’s clinical characteristics, rather than the amount of therapy provided. The new system seeks to remove incentives to maximize reimbursement levels by providing more therapy than medically necessary.

PDPM is likely to bring about increases in group and concurrent therapy—a phenomenon that, along with the move away from therapy volume, appears to have driven the staffing and pay reductions seen at some SNFs (note that not all SNFs have responded this way). According to an ASHA statement on PDPM effects, issued last week, “Workforce reductions are not warranted since there are no significant reductions in reimbursement for delivering medically necessary care.”

Medicare implemented PDPM in a budget-neutral manner, meaning that the industry as a whole receives the same Medicare reimbursement under PDPM that it did under the RUG system. Given this, the expectation is that facilities providing appropriate levels of medically necessary care are unlikely to face significant reductions in payment. Staffing changes in SNFs thus are related to business decisions, rather than financial hardship, according to ASHA health care policy staff.

At this point, the SNF workforce reductions are difficult to quantify due to a lack of systematic reporting, but they may be as high as 6%. Branch says OT and PT assistants have been hit hardest, as part of some companies’ reaction to PDPM’s shift away from treatment volume. She notes that only a third of the rehab staff are left at one of the facilities she worked for. At another, those who lost jobs include an SLP and mother who is on unemployment because part-time jobs won’t cover her childcare costs. At the Georgia SLP’s former company, all the PRN staff had their pay cut.

SLP Julie Fechter has been monitoring SNF social media sites since PDPM took effect, and says she knows of job losses in Texas, Ohio, Nevada, Utah, Florida, and California—and there are no doubt more. The biggest job losses seem to be in Texas and Florida, she says. Based in Seattle, Fechter left SNFs for other health care sectors six months ago because of concerns about her clinical judgment being compromised.

Treatment reduction

Another effect of the business reaction to PDPM, says Branch, is a marked reduction in amounts of therapy provided to each patient, even though CMS requires that patients receive all medically necessary care. An SLP friend of Branch’s has been ordered through a SNF’s administrative mandate to limit treatment for each patient to 13 minutes, while being pushed to achieve 100-plus% treatment productivity. “That makes for an extremely stressful day,” Branch says.

Such a treatment approach is unethical, notes Tim Nanof, ASHA’s director of health care and education policy. “It violates the clinical judgment of the therapist and cannot meet the individual medically necessary needs of the patient,” he says.

The SLP left at the Georgia SLP’s former SNF is also under pressure: She’s taken on her laid-off colleague’s caseload of 15 to 16 patients, in addition to her duties as a manager. Sometimes the work is falling to OTs and PTs, “who don’t know how to be us,” the Georgia SLP says. She worries that her former patients won’t get the quality help they need with cognitive skills and swallowing.

Another West Texas SLP—who lost her SNF job on Sept. 30 and also wishes to remain anonymous—still provides services there sometimes and is concerned about the drastic reduction in treatment minutes from 45 to 15, which, she says, clearly goes against meeting patients’ needs (which did not change on Oct. 1). “I had a two-week post-trach removal patient who has speech, language, voice, cognition, and swallowing deficits and was given 15 minutes with him today,” she recounts. “He had a swallow study today. I had to get him awake, provide oral care, place dentures, do swallow exercises, provide trials, redo oral care, call the SLP at the hospital doing the MBSS to inform her of the patient’s deficits, talk to the SLP on the phone following MBSS to hear about his new diet, document and write new diet orders, and educate the staff, family, and patient. In 15 minutes. Not possible. I billed more than 15 minutes for my services and probably still did not bill enough. That’s just one case of many. This can’t happen! There has to be a better system. My patients deserve better.”

This type of situation breaches the federal Fair Labor Standards Act, notes Nanof. “SNFs and rehab agencies can’t break the law, and our members shouldn’t give away their services for free,” he says.

Adds Sarah Warren, ASHA’s director of Medicare policy: If you feel pressured to do anything that’s clinically inappropriate for a patient, immediately speak to your SNF administrator—and if that doesn’t help, report your concerns to corporate compliance, the state, or Medicare. Ultimately, she says, per ASHA’s ethical standards and standards of practice, SLPs’ clinical judgment, and not administrative mandates, should drive clinical decisions for patients.

 Editor’s note: Questions about navigating changes at your SNF? Contact Monica Sampson, ASHA’s director of health care services, at healthservices@asha.org. For questions specific to PDPM and Medicare, contact Sarah Warren at swarren@asha.org. Also, an upcoming episode of the ASHA Voices podcast will feature SLPs’ PDPM experiences. If you’re interested in being interviewed, email podcast@asha.org. Or leave your story (anonymously if you wish) on the podcast voicemail at (301) 296-5804, and we may include it in the episode.

Bridget Murray Law is editor-in-chief of The ASHA Leader.

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Chris October 10, 2019 - 8:30 am

I joined the ranks of newly unemployed therapist after 20 years of service to Genesis. Not so much as a thank you. Just told me as well as 4 other staff 9/30 was our last day. Went in on oct 2 to get the rest of my personal belongings and was shocked to see unknown therapists there some as far away as 90 min looking bewildered and completely lost. These minions are being spread out over the state to get treatments done and move on to their next building even farther away. Most were DPT’S who obviously have thousands of school loans to pay back so they accepted the prn option I declined because I’m not spending my day in my car driving 100 miles when I live 5 min from this facility. One therapist told me shes leaving her house at 5am and not getting home until 6-7 o’clock at night. I have small children and to think this is acceptable when over the past 2 years I was barely working 30 hours a week. This is criminal. Corporate greed is why all this happened.

Bridget Murray Law October 10, 2019 - 10:11 am

HI Chris, We are terribly sorry that this happened to you. We are collecting ASHA members’ personal stories of how PDPM has affected them, which we plan to publish anonymously online. Would you be willing to have what you wrote here included? Please let me know yes or no. If you would like to add or anything to it and/or edit it, please email the version you’d like used to me at bmurraylaw@asha.org by this coming Monday, Oct 14. Again, sorry you have experienced this. Work is ongoing to address the situation, and, meanwhile, we wish you the best in landing on your feet.
–Bridget Murray Law, Editor-in-Chief, The ASHA Leader

SNF assistant October 12, 2019 - 2:50 pm

In the facility I work for we started doing groups of 4 residents without a transporter or an additional equipment. To make a long story short we rarely manage to gather all patients on time to provide group therapy. There are refusals, outside appointments and all as usual (headaches, time is not good, and such..)Usually we deal with total chaos and we are cutting corners to provide some sort of physical mobility, but the quality of treatment is down. The facility management suggest however that we bill patients as a group, those who don’t will be the first to go. We are all scared to loose our jobs all of the sudden and we feel terrorized by this situation.

Traci October 15, 2019 - 4:30 pm

I’m in a similar boat. I do PRN work as an SLP in an Ohio SNF and drive 45 minutes one way. I was informed that as of November 1, my pay rate will be reduced, but wasn’t informed on how much. I will most likely be exiting the field, and moving on to a career that is more stable financially. It’s a real shame, because I had an awesome working relationship with both staff and patients. Many of us are being forced out, and who suffers the most: our patients do.

Outofwork October 22, 2019 - 7:17 pm

I too got laid off, along with 4 other therapists in my building. I was with company for 12 years. Now they are using PRN!!!! An they just open PRN positions… going to go back to waiting tables, no jobs in area. Thinking about going back to school, need to get away from Medicare!

Bridget Murray Law October 23, 2019 - 1:04 pm

Traci and “outofwork”: Thank you for sharing your experiences. We are troubled to hear this has happened to you. My suggestion is that you contact our health services team at healthservices@asha.org for guidance on your situations. –Bridget Murray Law, editor-in-chief, The ASHA Leader

Ed Watters October 29, 2019 - 10:06 am

Since Medicare announced that the change to PDPM will be revenue neutral, in other words they still intend to be paying out the same amount of money to the SNFs, and therefore, the rehab companies that hire us, Medicare is in effect saying that this is not a cost control tactic, but a tactic to decrease payments to the people who actually work with the residence of the nursing homes.

Lorraine C Mangan November 5, 2019 - 5:20 pm

Looking for further advancenent in my career, I applied and was hired in March of 2019, as the second SLP to join the rehab staff in meeting the increasing amount of admitted patients in need of speech therapy services per physicians’ orders. As colleagues began to know me through my consistently high standards of professionalism, a growing request for consultations were referred to me via the nursing department and therapy staff. Following excellent ratings obtained from my employee evaluation documentation, and the frequent verbal praises obtained from my patients and their family members, my employment, and that of two other advanced level clinicians (20 years experience), was unexpectedly and suddenly terminated on November 04, 2019. A single entry level SLP therapist was hired just days prior to our termination. PDPM means that corporate greed is the one who is really in the driver’s seat and NOT the victimized patient or their advanced level therapist!

Jill December 5, 2019 - 7:12 am

I don’t think it is corporate greed alone I believe that Medicare should be audited and reforms need to be made by practitioners and not fiscal management, after all we are dealing with human beings not merchandise. We have licenses and degrees and are treated no better than factory workers. Productivity, timed patient care, no missed visits allowed, no documentation outside the visit, etc, etc etc. I loved being a therapist 25 years ago but I am glad to be retiring soon. As someone said, the only jobs now are PRN. I would not have been able to support my family if this happened 15 years ago. I think its a disgrace, especially to the PT’s who have been mandated to get Doctorate degrees to practice. Why bother? I know waitresses making more money than I do and have the same benefits as PRN staff.

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