Would Proposed CMS Changes Shape the OT Scope of Practice in Skilled Nursing?

In an earlier post, we covered the Centers for Medicare and Medicaid Services’ (CMS) proposed changes to the skilled nursing facility (SNF) Prospective Payment System (PPS) from May 2017.  In that article,”How CMS’ Proposed Changes to the SNF PPS Could Hinder Access to OT Services,” we discussed how the proposed rule could make it difficult for SNF patients to access occupational therapy (OT) services. Today’s article looks more closely at how the OT scope of practice in the SNF setting could be affected by the proposed changes.

If the CMS Proposed Changes to the SNF Payment Model Go into Effect in 2019, What Would this Mean for PT and OT Practice in Skilled Nursing?

The American Occupational Therapy Association (AOTA)’s position on the proposal raises a primary concern over skilled nursing facility (SNF) patients losing access to needed occupational therapy (OT ) services due to challenges in classifying patients into too broad a category system that can fail to accurately and comprehensively identify a patient’s needs. Other major concerns raised by the AOTA consider the fact that the RCS-I payment determinant component for rehab therapy services would combine both a patient’s physical and occupational therapy needs. Without a distinct differentiation between physical therapy (PT) and occupational therapy needs, a lumped payment amount allotted to meet all of a patient’s OT and PT needs could result in the insufficient provision of either service if the payment is not distributed proportionately according to the patient’s respective need for OT and PT.

Further, RCS-I’s lack of distinction between clinical characteristics of patients having both OT and PT needs also brings to light the issue of the medical community not fully recognizing what OT is and how it is specifically and uniquely distinguishable from PT. In fact, the proposed RCS-I fails to fully factor in cognitive impairment (a domain specific to OT’s scope of practice) when clinically classifying a patient’s need for OT. Such an oversight exemplifies how the misperception of OT’s scope of practice continues and has the potential to become further entrenched if action is not taken to continue educating the medical community and promoting OT.

Altogether, the concerns highlighted by the AOTA bring forward a picture of the impacts the RCS-I would have on a practical, everyday level. Conceivably, OTs could identify patient needs that cannot be addressed if the RCS-I payment allotment for a combined PT/OT need is insufficient to treat all identified OT needs; or, an identified OT need could be unclassifiable per the RCS-I’s preset clinical categories, ultimately forcing an OT to leave that patient need untreated.

Further, in the case of uncategorizable clinical OT needs, some SNF patients may be considered to have no OT needs at all. Consequently, patients who fail to receive adequate therapy services would be placed at risk for further functional decline, directly impacting their short and long-term health and safety. For OTs, being unable to provide services for clearly identified needs introduces professional and ethical dilemmas. These potential consequences of employing the RCS-I would certainly make ensuring patients’ rights to medically necessary treatment and sound clinical practice by OTs a great challenge.

Modifying OT Practice

Should CMS’ proposal become a final rule, OT practitioners may encounter instances where they are unable to provide all of a patient’s therapy needs and would then be required to reconsider ways to provide a patient all necessary OT services in a system that may make this seem impossible.

[Read also: The Distinction Between Key Rehabilitation Providers and Their Roles in SNF vs Homecare Settings – Part 1 of 4 (Key Providers)]

As an example, from the start of care, SNF OTs can look ahead to post-discharge settings that may be able to manage a patient’s remaining OT needs following discharge from SNF care. This would mean that an SNF OT may have to aim not to fully restore a patient’s prior level of function (PLOF), instead setting long-term goals to bring a patient to a minimum functional level that ensures their ability to safely perform basic activities of daily living (ADL) within the home, but perhaps does not necessarily allow the patient to perform higher skilled instrumental ADL (IADL) or activities within the community. Upon discharge to home, a patient could then access outpatient OT services to achieve full restoration of their PLOF.

Such a treatment approach may also necessitate even more treatment time spent with patient caregivers, which in effect could also be another route through which OTs can address patient needs that are unclassifiable per the RCS-I and perhaps untreatable. For instance, an SNF patient could present with a cognitive impairment affecting his/her safety though is not considered to have an OT need if the impairment was not identified by the cognitive assessments designated by the RCA-I for use in the patient cognitive assessment. Even if the patient has the rehab potential to be independent with his/her ADL using compensatory techniques that address the cognitive impairment, if an OT is unable to directly address the impairment, the OT can instead turn to caregiver education and training in the use compensatory care strategies. This way, although the OT may be unable to increase the patient’s functional independence as would be the actual purpose for OT intervention in this case, he/she can still address the effects of the patient’s cognitive impairment and ensure his/her safety with ADL at home by way of caregiver training.

Modifying our OT practice to account for what we can’t do is definitely not the ideal way to provide treatment for our patients, but it is a must to allow us to do what we can. All in all, it will certainly help mitigate the negative effects the RCS-I could potentially bring to our clinical practice.

Navigating the Future of SNF OT Services

As time will reveal what the SNF environment will become for patients and therapists, one thing OTs can steadily rely upon is our natural ability to find resourceful ways to modify a situation so that we can still achieve the desired outcome.

If we can leverage this tendency toward adaptability to do the best we can to provide care regardless of the reimbursement rules, it will be a much more manageable task to keep the protection of our patients’ rights to healthcare at the forefront of our work. Equally important will be the need for all OTs to continue advocating for our profession, ensuring the healthcare community is correctly informed not only on OT’s scope of practice but the value of our services.

[Read also: Adaptations For Maximizing the Person-Environment Relationship]