In the wake of the implementation of the patient-driven payment model (PDPM) in skilled nursing facilities on Oct. 1, many speech-language pathologists experienced negative effects—including layoffs, pay cuts, changes in job status, and less treatment time for their patients. Many shared their stories with us, and some of them agreed to also publish them here, anonymously. Here are their stories …
I work … at a building with a skilled nursing home, with assisted living and independent living. We have a staff of 14 therapists of various disciplines. Yesterday I thought we were complexly safe as we were told Rehabcare was staying status quo. Today it was announced we will be doing groups and concurrents and we will have shorter days—not full days.
We are not supposed to ever get overtime. We will no longer have prn’s—which will mean the loss of jobs. So far no changes regarding weekends, as all the evaluating therapists already work a weekend a month. I am sure more changes will unfold as Corporate arrives next week. Our facility is going to look at the contract again in six months, and that’s when cuts might be made in my mind. Thanks so much.
I am an SLP for Reliant Rehabilitation. On Monday, 9/30/2019, I received a call from my regional director that I would no longer have a position floating between my two facilities where I have been working for the past year and a half. There are now not enough hours for three SLPs between two facilities, even though I have always gotten 40 hours, or at least close to 40 hours. I was offered a position at another Reliant building under the direction of another regional director. It sounds like I got lucky in that I still have a job—however, if it weren’t for the SLP at the facility I was offered, I would have been let go from Reliant all together.
I have been helping out at one of my old facilities, and minutes have been significantly dropped from 30-45ish minutes down to 15. I had a two-week post-trach-removal patient who has speech, language, voice, cognition, and swallowing deficits and was given FIFTEEN minutes with him today. 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 patient’s deficits, talk to SLP on phone following MBSS to hear about new diet, document and write new diet orders, and educate staff, family, and patient. IN FIFTEEN 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. These big corporations trying to beat the system and get more money have got to go. Medicare needs a better system if they do not see the other comorbidities as important. Please help.
I have been a certified speech-language pathologist for 3.5 years now. I have been employed at the same building for my entire career. Recently, a year ago, a rehab company took over our building and has been pushing for ultra-high RUGs ever since. The unethical behavior didn’t stop there. I was notified on the 16th of September, conveniently two weeks prior to implementation of PDPM, that beginning on 10/1/2019 my full-time status was being reduced to part time.
Our therapy manager is being forced to take two hours from my caseload every day, despite her requests to work less hours and allow me to maintain mine. She is now required to “be productive,” i.e., have billable time make up 20% of her day, no matter how many hours worked. To top it all off, we were notified today if we do not begin implementing group and concurrent therapy sessions, our wages will be reduced. Our building has already been cut one full-time certified occupational therapy assistant and physical therapy assistant. This behavior has got to stop.
Regarding the nationwide panic as a result of PDPM, I am writing as I am one of the victims to this change. My company forced me in to a pay cut and forced me into transitioning from hourly to salary. I was told that the changes were due to cutting extraneous costs for the company. How insane that my livelihood is considered an extraneous cost. I fought hard for my worth, and the value I add to my facility, and it essentially got me nowhere.
It was extremely heartbreaking and a devastating blow to me and my family to unexpectedly lose such a significant chunk of my income. I … wish to remain anonymous out of fear of retaliation. I wanted to share my experience with you. This is not right. None of this is fair to any of us. Our profession is bleeding. Prayers for us all. Thank you for being a voice for all of us.
I’d like to stay anonymous, although I would like to bring awareness to what is happening in our field. I had just completed my CF with Encore Rehabilitation Services this past August, when they gave me a raise of $2 (when I was told it would be $3–$4) and the regional told me it was non-negotiable since they were in a “pay freeze.”
Halfway through September, one OT and two PTs (who are new grads and started the same day as me) had been let go due to these upcoming changes and “downsizing.” I felt as safe as I could have been but guilty at the same time knowing that just because I’m an SLP and we are a bigger component, that we would be needed. Come the end of September, Encore announced via telephone across all buildings that there will be 5% pay cuts for all employees. All I’m wondering is, where is all this money going to? I’ve heard of companies doing pay cuts but not letting employees go and vice versa, but the fact that Encore did BOTH within the same month disgusted me.
I had planned to go PRN with the company for months already, since I was burnt out and overall unhappy with the drastic change in both the DOR and regional director within the span of 1–2 months prior to October 1. I even tried to negotiate my PRN rate with Encore since I was receiving a fair PRN rate at another SNF I work for. The PRN staffer refuses to communicate with me via email and only calls me. She reports that they just received these “new rates,” and that it’s not negotiable. Mind you, the going PRN rate for the central NJ area is around $55, and Encore is offering $5–$6 less. I’ve decided to stay on as PRN for the sake of my amazing CF supervisor who I still work with in the same building. If it were not for her, I would have quit months ago.
Encore does not value loyalty or performance, and has always been looking to hire new grads for cheap and cycle them through the system. It’s terrifying to see how this field is not what I thought it was coming out of graduate school. I thankfully am switching to the outpatient setting in the next couple of weeks, and I couldn’t be more excited. I urge ASHA to stand for a change for what’s going on in the SNFs and especially for new CCC-SLPs. We did not go through 7 years of schooling and training to be disrespected in this way.
Casualty of PDPM
I was a CFY and SLP at the same SNF for 5 years … and was let go with a handful of other therapists. Our last day was September 1. Our facility decided to move in-house and did not renew their contract with Encore Rehab Services, and I have no doubt that it was due to PDPM. There was no other explanation as to why I was let go.
I have been providing quality care, supervised numerous graduate students, consistently and ethically met productivity requirements, and kept on top of my documentation. I have been lucky enough to have had a PRN job lined up fairly quickly and recently took on a part-time job at Encompass Health in patient rehab (my first day was on Wednesday). I know that I am one of the lucky ones simply because I was let go early … I know of at least two other SNFs in the area who also cut some of my other SLP friends due to PDPM.
I’m in a similar boat. I do PRN work as an SLP in an … 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 as how much. As far as pay cuts go, this is quite a blow … in particular to experienced therapists who have already been receiving the same pay rate since 2003! Is it even legal for an employer to cut pay if I refuse to sign a contract?
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.
PDPM: Two concurrent tx and one medical dx
I am a speech-language pathologist with 20 years’ experience in health care, predominantly SNF. Currently I am working as a PRN therapist for multiple companies (multi-state in-house, family-owned in-house, contract therapy). I would like to share three recent experiences with you.
Concurrent Experience 1:
One facility (in-house and owned by a small multi-state chain, which I am employed by) implemented the group/concurrent model as soon as it became clear that there would be punitive risk for change in practice pattern as of October 1. Prior to that all therapy at this facility was provided individually. I arrived for work one day to cover for the vacationing SLP and was presented with a schedule to do a concurrent treatment with two patients, one of whom I had recently provided therapy for (cognitive communication) and the other who I did not know (dysphagia).
The cognitive communication person was confused in the environment and required consistent interaction to remain engaged. He was independent in wheelchair mobility. The dysphagia patient was complicated and low level on paper and in person was even lower level. My plan was to engage the cognitive person in conversation regarding something pertinent to his plan of care while providing therapeutic texture trials with the other patient. When my attention was on the dysphagia patient, the cognitive patient would leave, distracting me from what the dysphagia patient was doing in order to return him to the session.
Upshot: the dysphagia person aspirated. That shouldn’t have happened. I felt (and still feel) responsible. I am ashamed that I didn’t refuse to do what’s right and not provide therapy in this manner.
Concurrent Experience 2:
On October 2 I arrived at work at a facility (contract therapy, “sketchy” company which I am employed by) where I provide therapy one half-day per week. I am scheduled for a concurrent session with two residents, one of whom I have worked with for the previous two weeks— recently admitted middle-aged man, long-term care with Parkinson’s disease, voice therapy to increase loudness. Patient is fully able to exercise at 85 dB with effort. Second patient I do not know—recently admitted, older man with mild cognitive impairment. Patient with Parkinson’s has been in bed the previous two sessions and getting him out of bed is not easily accomplished. That morning nursing ordered the second patient to be in bed because of new swelling in his ankles.
Disregarding the issue of getting these two people together even before the edema issue (that in itself would be two paragraphs of typing), there is the problem of how to provide the therapy they need in such a setting. The therapy manager suggested bringing them both to the gym, putting one on one side and the other further away. Evidently, I was supposed to just rocket back and forth between them providing some brilliant piece of therapy each time. This session did not happen because of the logistics and because finally the manager said, “If it doesn’t work, it doesn’t work.” Not to mention the fact that the patient working on voice would be doing his voice therapy at very loud levels, disturbing everyone in the environment.
I’d like to mention that this particular company decided on October 1 to start groups and concurrents—just told the therapists to do it with no guidance. This is the same company that cut PRN wages 3%.
Experience 3—Medical Diagnosis:
Today I worked at a facility which contracts with a therapy provider (which I am employed by). I am supposed to screen and evaluate appropriate patients who have been admitted. The physical therapist informed me that she had just evaluated one new admission person who needed speech therapy secondary to cognitive impairment; he was unable to retain the information she provided him regarding pursed lip breathing, and he demonstrated no insight to the issue of desaturation with ambulation. I had time for one evaluation today, and quick screens of the other two admissions revealed this person was the priority.
The person had 18 discharge diagnoses. Not one of them would be a primary factor for his cognitive communicative impairment (and, by the way, none of those diagnoses were accompanied by their ICD-10 codes). The physician had commented in the narrative that the patient had been hypoxic … but that wasn’t a diagnosis on the list. Upon further review of his admission packet I noted that one of the consulting services documented the patient was a poor historian (his wife did the report) and eventually the patient stated he had some memory loss. But he did not have a neurocognitive diagnosis.
I searched Google for the term “hypoxia ICD-10” (because that’s the way excellent health care should be provided right? a Google search) and entered R09.02 as the medical diagnosis. I was not allowed to use that diagnosis per our electronic medical record. It was marked “return to provider.” So I entered the same code used by PT and OT, which really isn’t appropriate. And who knows what will happen? Will this claim be kicked out and not paid? This person needs speech therapy, which he will receive but the company might not be reimbursed. Making speech therapy look like the culprit.
I would like to note here that this company is guilty of instituting [expletive] groups that are somewhat helpful generally but are NOT what patients need from therapists: for instance, the “admission group” run by occupational therapy to orient new admissions to the facility and what all the different disciplines do and where the cafe is located. Truly all good information. But that hour was one less that wasn’t focused completely on them and their rehabilitation. And that’s just one of the 10 groups scheduled each week (not every patient is in every group).
I am so conflicted about what to do. As a human being fighting for what is right and taking care of my patients, I should refuse to provide treatment that places them at risk, let alone provides suboptimal care. They have a right to the best care. Isn’t that what they’ve paid for?! As a PRN employee I will lose my employment if I refuse to do what my companies ask. They will call someone else. Concurrent and group therapy are rarely appropriate in speech therapy—speech therapy demands individuality. If it were truly up to the clinician then, and only then, would I trust that it was being provided in a clinically appropriate manner.
Go fight the good fight!
Replaced by an assistant
With only a few days left in September, I was terminated from my position as the rehab director. Initially, a physical therapy assistant and certified occupational therapy assistant were laid off as well. One of the assistants was offered status as a PRN employee. The other assistant was offered a managerial position at a facility outside the “typical” driving range, with the hope to move back to this home facility. Within the layoff conversation, the regional director also offered another managerial position in a neighboring state in which the assistant was not licensed. However, within a two-day period, the company decided to remove me as the director. In addition, the two alternative positions initially offered to the assistant were reportedly filled and the only position available at that point was to move this assistant, who had been initially laid off, into my position. This assistant was told either take my position because I was being terminated or they wouldn’t have a job either since my director position was the only one available.
I was notified of being laid off via telephone (Bluetooth) while I was driving. I was not asked to pull over to talk, nor to return the regional director’s call once I was able to talk. In addition, my staff had to tell me who was replacing me. The assistant who days before was not needed was suddenly replacing me.
Affected by PDPM
I am an SLP who was recently affected by PDPM changes. I worked for a small company (owned by a physician and other individuals) called Global Rehabilitation/Select Care Excellence. The actual SNFs are called “The Medical Resort.” There are several locations in the surrounding Houston areas, including The Medical Resort at Bayarea, The Medical Resort at Sugar Land, The Medical Resort at Pearland, etc.
They initially reduced our rates in August and told us that we would have to be “flexible” when PDPM arrives, to not worry about our jobs, but we may have to float between buildings. The last week of August, they sent us a letter which I will attach for you to see. They decided to make job cuts and we (PT, OT, SLP) had to re-apply within three days for the new positions that were now available. I’ve attached the first page only, the second and third pages were the positions that would be available at all the buildings. Many therapists were let go between all the buildings, some decided to leave on their own to work for other companies. There was no position for me based on that letter (they wanted one SLP to float between two buildings and I was unable to do that). Thankfully, I remained connected with my PRN companies, which I found work with.
Not only did they fire several therapists within days, but they have reduced therapy minutes to 30 for all disciplines effective August/September in anticipation of PDPM. They hired additional rehab techs so they can do “exercise” activities (on weekends) with the patients to make it look as if they’re getting “therapy” daily. The rehab techs are not billing this, of course, but it’s almost a front for the patients and their families that they’re keeping the patient “active” even though the skilled therapy isn’t there. The therapists that have remained are expected to group and do concurrent therapy even when not appropriate, and they have to work one weekend a month so that they don’t use PRN when possible.
This has been very upsetting for all of us and I believe it is our duty to report these unethical companies. I absolutely loved my patients and was so disappointed to see what is being done to them. In the summer they’re all receiving 40–75 minutes of therapy for each discipline, but once Sept/October came along it reduced to 30 minutes across the board. I am happy to say the PRN company I’m working for now is not doing this, so I know there is hope out there. I hope Medicare is truly going to go by their word and go after these companies. I guess time will tell. Thank you for your time.