Policy Talk
Defining "Intensity of Therapy" by Ellen R. Strunk PT, MS
A recent manuscript accepted for publication in the Physical Therapy & Rehabilitation Journal (PTJ) caught my eye as it likely did others. Its title was Rehabilitation intensity and Patient Outcomes in Skilled Nursing Facilities in the United States: A Systematic Review.1 The reason it attracted attention is not a surprise. Discussions about the intensity of therapy are not unusual and have dominated listserv discussions, online media content, and industry meetings for several years. However, the tone of those conversations has evolved. For many years, they were focused on the exponential increase in the level of therapy services delivered in skilled nursing facilities (SNFs) and home health agencies (HHAs) driven by what many perceived to be “incentives” in the prospective payment systems (PPS). When the Centers for Medicare and Medicaid Services (CMS) announced their intention to radically change the PPS for SNF and HHAs to the Patient Driven Payment Model (PDPM) or the Patient Driven Grouper Model (PDGM), the conversation quickly flipped. Discussions forecasted a reduction in therapy services due to the fact that they were no longer the “revenue producer” in these new payment models. Then the Coronavirus pandemic raged throughout the country. All our energy and attention turned to keeping patients and ourselves safe. The Secretary of Health and Human Services (HHS) declared a national Public Health Emergency (PHE) and nursing facilities, assisted living facilities, and even the homes of older adults became a location many therapists were no longer welcome. The last 12 months have probably created more questions than answers when trying to analyze practice patterns and data. CMS announced it would not be using data submitted in quarter 1 and quarter 2 (January 1, 2020 through June 30, 2020) for the post-acute care settings’ respective Quality Reporting Program (QRP) compliance calculation, nor for public reporting. Regardless of whether the information will be utilized for these
purposes, data submitted for purposes of payment will still be available to CMS as well as providers. Will it be possible to discriminate between patient outcomes related to intentional practice changes as a result of the PDPM or the PDGM versus unintentional practice changes as a result of the PHE? Can we appropriately attribute the effects of higher or lower therapy intensities that may have occurred?
This article is timely for the profession because it addresses questions that many have been grappling with over the last couple of years: Is a higher intensity of therapy more effective? Will lower levels of therapy have a negative impact on patient outcomes? The authors of this study reviewed available evidence to evaluate the relationship between therapy intensity and patient outcomes in SNFs. With the exception of one study, they included all therapies (physical, occupational and speech therapy). Patient outcomes were defined as length of stay, discharge to the community, hospital readmissions, and functional improvement scores. Examples of the functional improvement measures are listed in Table 1. Four studies examined the relationship between therapy intensity and successful discharge to the community or home after SNF admission. All four detected a consistent dose-response relationship of higher likelihoods of community discharge as therapy intensity increased. Although the magnitude of the effect varied across the studies, there was a dose-response relationship. Only one study examined the relationship between physical therapy hours per resident day and the risk for
Table 1: Examples of Functional Improvement Measures Functional Independent Measure (FIM)
Measures function in 13 motor areas and 5 cognitive areas, with items rated on a scale from 1 to 7 (7 indicates total independence)
FIM divided by Length of Stay
A measure of efficiency
Short Physical Performance Battery (SPPB)
A measure of lower extremity function which includes gait speed, sit-to-stand, and balance items
Gait Speed
Gait speed scores have ben shown to predict disability, morbidity, and mortality
Ranking of independent in activities of daily living (ADL)
The Morris scale from the Minimum Data Set (MDS), with scores ranging from 0 to 28 (28 indicates total dependence)
GeriNotes • March 2021 • Vol. 28 No. 2
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