By Heather Jeng
Lately, it seems like litigation against skilled nursing/long-term care therapy providers is becoming more frequent. See, for example, this recent story about the DoJ pursuing a case against ManorCare (owned by The Carlyle Group) for allegedly providing medically unnecessary therapy. As therapists, we might ask, “How could the company itself provide medically unnecessary therapy? Each plan of care was generated and signed by a skilled, licensed therapist.” According to the article, “ManorCare allegedly set prospective billing goals designed to significantly increase revenues without regard to patients’ actual clinical needs and threatened to terminate SNF managers and therapists if they did not administer the additional treatments necessary to qualify for the highest Medicare payments. ManorCare also allegedly increased its Medicare payments by keeping patients in its facilities even though they were medically ready to be discharged.”
The description of a rehab company work culture in which therapists perceive explicit or implicit pressure to go against their better judgment when making recommendations is not surprising. Multiple forum posts (Facebook speech-language pathologist (SLP) groups, ASHA Community discussion forums, etc.) provide examples of these perceptions. Some therapists report that they are not “allowed” to discharge patients or decrease the intensity or frequency of services based on their clinical judgment. Read these forums long enough, and you’ll become familiar with the disturbingly high levels of cynicism that some therapists succumb to in this setting. To wit:
I don’t mean to seem humorless, and I get that we all need to vent sometimes. And sure, every field has its own version of gallows humor. But I can’t decide what’s sadder: the meme itself, or the fact that it got 400+ likes in the first two hours or so it was posted.
I don’t have hard and fast data, so it’s difficult to say definitively what’s contributing to the unpleasant work climate in some SNF/LTC settings. (I do want to emphasize that it’s only some. Others are wonderful, and work tirelessly to provide their residents the best possible care and to take care of their employees.) Anecdotally, it seems that SLPs in SNF/LTC are often the solo SLP in their facility, and therefore don’t have the benefit of speaking up as a group at the building level. Again anecdotally, some CFs in this setting report a high incidence of off-site mentorship during their Clinical Fellowship Year. How about the fact that these positions are generally paid hourly, rather than salaried–despite the professional degree required–and therefore result in financial insecurity from week to week? Does it make a difference that speech-language pathology is a female-dominated field, and some likely experience discomfort and uncertainty negotiating and managing conflict in the workplace, and tend to be people-pleasers? Probably, but that’s not my area of expertise. And ultimately, none of these possible factors can be a valid reason for making anything other than our best clinical judgment and standing by it.
One issue I have only seen discussed occasionally is the perception of the value of SLP services by other healthcare providers. I have come across social media reports of physicians and nurse practitioners being reluctant to order speech therapy for cognitive-communicative treatment, particularly for residents with dementia, in the SNF/LTC setting. If it is true that some of these facilities and rehab companies push for inappropriate levels of therapy–in other words, if staff perceive that all we do with certain patients is pick them up for “memory strategies” and then discharge in a couple weeks, with no apparent functional benefit–it becomes difficult to blame the MDs and NPs for having that skepticism about the value of speech therapy.
It can absolutely be exhausting to have a high level of stress in the workplace. But we need to consider the long-term ramifications of letting our clinical judgment be influenced by workplace pressures, whether explicit or implicit. We’ll suffer professionally for it, but ultimately, it’s the patients who need help communicating who will suffer the most. We need to eliminate the mindset of being “allowed” to make particular recommendations. We are independent, clinically trained health care professionals. We don’t request permission to make our recommendations. And we need to stand firmly by our clinical judgment. Not letting ourselves be pushed around is a form of patient advocacy.
Resources for SNF/LTC SLPs on this topic:
- How to Report Medicare Fraud and Abuse by the ever-helpful Gray Matter Therapy
- Consensus Statement on Clinical Judgment in Health Care Settings by ASHA, AOTA, APTA
- Medicare Guidance for SLP Services in Skilled Nursing Facilities
What about the rest of you SNF/LTC SLPs? Perspectives? What situations have you and any SLP coworkers faced in your own SNF/LTC, and how did you address them? Any other helpful resources?