Future Thoughts for Private Practice Physical Therapy

Private Practice Physical Therapy (PPPT) 

"It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way." - Tale of Two Cities, Charles Dickens.

I feel that the quote above truly describes the state of affairs in PPPT. Never in the history of the industry has so much potential been met by so many barriers. With the chaos in the healthcare industry at large, the instability of the economy and marketplace, as well as the terribly amorphous state of physical therapy practice in its vast diversity - it is getting harder for suppliers to convince consumers in the value of a private practice (and many times cash based/out-of-network healthcare service).

Bleak. Huh?

Well, I was asked a little while back to describe my vision of a Utopian, outpatient PPPT clinic. As you know, while being an overall optimist, I'm a realist, a tactician, and a businessman. Despite the picture being painted in such depressing colors, I believe there are still many venues for which physical therapists can strengthen their position in market. Additionally, there are new possibilities which will not only redefine physical therapy, it will redefine certain facets of healthcare (by which, REMIND me to write a post on the futures for future thoughts on inpatient PT).

So, here's my vision:

I envision the future proprietor of PPPT to serve as an owner of businesses, a provider  in outpatient clinics, a health/wellness consultant, a concierge home health practitioner, as a health fair/conference/talk-show/media speaker, a retailer, and as a community leader.

As an owner: I see PPPT as a bankroll to own properties of strip malls, commercial office buildings, and the like. I see the openings for owning fitness gyms and even renting out to or owning (if able in respective states) massage therapy, acupuncture, chiropractic, nutrition retail, beauty salons, and any other associated wellness venues - in this vein, some people say "If you can't beat them, join them" - I say, "Just own them!"

I also see massive potential for PPPT in retail. I've already published some content on the matter:

• Business Opportunities: Services versus Products
• Another Disney Post: Learning Retail Smarts

The bottom line here is that physical therapists NEED to learn both the service business and the products-sales-retail business; there are many lessons to be learned from optometry, dentistry, chiropractic, and general retail. If there is any DME, orthosis, or any such health product you recommend or already place orders for, you should be retailing it!

HOWEVER, perhaps where the greatest opportunity in the future of PPPT is located is in primary care. While the future of healthcare is still quite uncertain, the future of human health remains largely predictable. People need a reliable expert for physical health. A primary physical therapist or a family physical therapist is desperately needed much in the same way a family physician, a family dentist, or a family optometrist exists in the market today. The pediatric PT for the growing family, the geriatric PT for the aging population, or your primary care generalist can all serve a very large market share for those who are frustrated with canned-fix-all "800mg of Ibuprofen mixed with muscle relaxers" - and/or - the ever popular "Well, that pain is just arthritis - you'll learn to live with it."

This type of primary care PT provider needs to expand past intervention and expand into yearly or biannual check-ups, wellness, pampering, prevention, and public education. This should also include hours of the day dedicated to concierge home health visits - a fairly profitable market, indeed! All this leads to an expanded exposure to the market at large; imagine when a family, very happy with your services, invites you to the kid's classrooms to talk about health for "show & tell".

Almost every kindergartener knows to "brush your teeth and floss daily." Imagine an entire generation who know from age five, if you are having pain, struggling with play (movement), fitness, or exercise - or - if you happen to have any muscle or joint problems; well then, it's time to see your family physical therapist! This type of appreciation elevates the PPPT to a point beyond a savvy business operator and expert health provider; this level of appreciation makes the future PPPT a community leader. Ever think of going into politics? Hint: expanding awareness, direct access, elevating scope of licensure.

Dreams to Reality:

Again, I'm a realistic and tactician - there needs to be a viable path to connect the dots to make such dreams reality. Here are some ideas:

First: *Quick soap box moment* When you Google "physical therapy," what do you see?

Apparently, the public thinks PT is passive range of motion, gait training, and perhaps ball exercises. Is this REALLY what we want? I've incessantly been on the soap box of brand image vs. brand identity in that brand failure occurs because a firm focuses on their own perception instead of the perception of their customers. Specifically, failure here commonly occurs because firms are silly enough to think that if they do the "right thing" in their own eyes, the public will be on their side.

For our industry, the naivete that the public will spend their dollars with sensibility/science/logic is an ongoing fallacy that only causes infighting within the profession - NOT helpful. Not convinced? Take a look at all the businesses in any industry that are not "evidenced based" but are obviously producing both experiential & financial outcomes satisfactory to the consumer. And, take a look at the bantering if not outright destructive arguments that are occurring in social media due, primarily, to personal (not professional) pride. It helps no one when methods, research, and/or experts are championed or demonized as an everything works or nothing works. ESPECIALLY in the current climate of evidenced based practice/medicine - we are only hurting our cause of solidifying a strong brand when research is purported as "nothing we do actually works" WITHOUT offering solutions to replace once viable interventions. All that such interactions are doing is narrowing the already limited scope of practice available to physical therapists - and - what is worse for PPPT, this is only decreasing the earning potential for reimbursement that insurance companies are willing to offer.

And so, I can't stress enough: consumers want to see brand UNITY (several posts on the matter are available below):

• Dr. Ben Fung's interview with Cinema
• Four Critical Rebranding Concepts
• #BrandPT: Marketing For Our Future

Inconsistency/infighting tells consumers to go somewhere else. Best example? Franchises. When some are good & some are bad, many consumers just go to the competitor. The lack of unity in the physical therapy brand is a failing causation; and, when a brand is failing, you rebrand. Period. To do otherwise with a good service or sound product is business suicide.

Enough of that. *Off soapbox*

Tactic: Marketing using an Island Hopping/Anchor Method
The best way to execute such a tactic is to find a (generally universal) signature moment for the common entirety of physical therapy (or whichever brand you are trying to pursue). This signature moment will become the definitive image for which the consumer will have in their minds as & for your brand. This image must also be adopted as your brand identity (even if this isn't what your ultimate goal is to be).

Now stay with me! This bit is a little long, but it all comes together at the end of this section.

Once you anchor this position, you have a strong base of fire for which you can launch an expansion. A possible example could be this: "Physical therapists specialize in recovery from injury." Translated: "If you get hurt, go see a physical therapist." This image implies that physical therapists are the experts which one can rely upon if one is experiencing pain or has gotten hurt in any way shape or form. While this doesn't even begin to cover the scope of what PT's do, this is a very important start.

From this starting point, we can build goodwill with the consumers we serve - starting grounds should be in the states where licensure is more limited. Conceptually, the conversation could unfold like this:

"Glad I was able to help you recover, Mr. Smith. You know what's interesting, I would've been able use more tricks of the trade if physical therapists weren't so limited in this state. Did you know that even though my doctorate degree teaches me how to (pick the most limited element in said state) diagnose, interpret imaging, read lab values, prescribe basic medications, perform joint manipulation, utilize dry needling, directly access my care, etc. - and, it is allowed in most states, you don't have access to such rights under my care?" This is point of service advocacy.

Whatever the battleground needs to be, using the brand experience of injury recovery (for this example), is the best way of expanding the brand to the next step. Example: it isn't too far of a stretch to say that: "If my PT can fix my injury, perhaps I can see my PT every 6 months to prevent future injuries (just like I do with my dentist for cavities)." Voilà! You have now anchored the "injury recovery" brand and now you are island hopping to the "injury prevention/best health primary care" service brand. Anchor down this brand, and the next target is yours for the picking. And yet, the most formidable barrier to brand expansion isn't the marketing aspect. It is the legal aspect. Ultimately, what we are licensed to do (or, not do) limits what we can effectually brand.

Speaking of brand, I know you're thinking: Wait a minute! Didn't the APTA stake claim to the "movement" brand; unfortunately, when you ask the general public about movement, they think about something more like a dance coach... movement simply isn't something the general consumer sees as a matter of healthcare - just my humble opinion. And, when rebranding doesn't occur en masse, it typically occurs in segments. We see this in fitness/personal training all the time with fitness fads. Moreover, we've seen this occur in our own profession with more accentuation in recent times. When one ditches a failed brand concept and begins branding the self, we observe people going to brands such as FMS/SFMA, MDT, NKT, PRI, PNF, NDT, Osteopractor, Kettlebell, TRX, CrossFit, Biopsychosocial, etc. But, why?! Isn't the physical therapist label enough?

Let's face it - private practice is a BUSINESS. In the end, there are bills to pay. There really isn't much time or space for idealism - for what should be or could be... the reality is that PPPT is the ultimate litmus test of what physical therapy is actually worth in the marketplace. When the blanket brand of physical therapy yields the images above... the brand is (in more than one dimension) failed for the private practice segment. Sure, there may be plenty of momentum in work-comp, large health systems, and/or inpatient care - however, this means very little to the private practitioner who has financially attached their homes to their business.

The only way the business can make a better profit is by churning more revenue. And, the only way to bring in more revenue is to expand the legal scope of practice. The marketing arm in this equation is to make well-known the SERVICES available; not the body of knowledge which surrounds the expert - for the consumer doesn't care about what you know. They care what you can do about it and how well you do it. Given, the "know" is more of an authority check point for what you do, certainly important - consider the know vs. what with an orthopedic surgeon. When they are recommended, they may make mention to how well credentialed the individual is, but ultimately, the prospective patient cares about their reputation for good surgical outcomes. How good is the surgeon at surgery? Are they allowed the perform the techniques they say they can do? The consumer could really care less about the rest of the information.

The same goes for physical therapy. FMS/SFMA brands for a systematized analysis of movement patterns to tease out and ultimately correct painful dysfunction. MDT brands for a uniform (again, UNITY!) method to address directional pain - primarily circulating around the spine. The newly trademarked (very smart business move, by the way) osteopractic approach focuses care on spinal manipulation and dry needling. These are services - and - the service is the brand. This service is the signature moment. And, it is from this signature moment that an entire industry can launch rebranding, brand expansion, legislative moves, and increase public goodwill.

The very definition of a brand includes consistency, a product/service which is uniform and reliable. In my interview with Cinema, I define a brand as:
"I define a brand as a symbolic, conceptual identity by which consumers imagine a firm’s services and products with accepted (or rejected) uniform consistency."

So my challenge to all of you: to private practitioners, business owners, managers, directors, to APTA leaders, and especially to #DPTStudent's - universally commit to getting over the uniqueness of your practice, your specialty, and/or your approach. Sure - our knowledge content may be movement & health. But what is our unified signature service moment? We need to define this service image - this moment when our consumers go "Ah ha! THIS is why I come to you (instead of someone else)." On this: what the above private brands are doing correctly is focusing on that signature moment - that's why they are in business! Plain and simple. As mentioned in one of my oldie posts, what our industry needs most is a Mickey Mouse Moment (see here & here) in order to launch a more effective marketing campaign in unison, as ONE profession.

So... what's our signature service moment going to be? Once we define this, expanding practice is just a matter of time. But, until then, our profession is building a brand structure on shifting ground. You want direct access? You want diagnosis rights? You want the ability to order labs, imaging, and prescribe medications? Do you want the military model? Would you like physician status and more authority to make a difference?

UNIFY.

Tactic: Community Leadership - Marketing for Future Generations

Here, I'd like to return to the concept of having every five year old in kindergarten know who to go to if they are ever hurt and/or in pain. Linking this to the signature service moment above, it would be best to partner with school systems and have physical therapist participate with physical education programs in K through 12 schools. Let your imagination stretch out once more to an entire generation who knows to get physical therapy FIRST when injured, physically impaired, in pain, or in poor health. THAT can certainly be our future.

This requires that people put their money where their mouth is; it requires PPPT owners to VOLUNTEER their time, energy, and resources at K-12 schools, health fairs, and community events. It is very likely that owners may have to (as some have, and, have won) stick their neck out in the legal world as well. While I understand many take the position that volunteer means free and free equates with less worth - I'm calling this concept out as short sighted marketing sense. This "free" is actually adding value to the marketplace community. It is raising goodwill which is generally considered a priceless heirloom in the world of business.

Since schools can't afford to have a PPPT contracted during Physical Education (P.E.), it makes most sense that absorbing the cost as a PPPT investment to raise goodwill amongst the students and parents/guardians is the best way to also involve the TEACHERS (powerhouse group, right there!). Just as years ago, so many kindergarten teachers had a "brush your teeth" time in the classroom (talk about best self-perpetuating marketing event, ever! - The return of investment: Best Paying Healthcare Job out there!), physical therapists have the same opportunity to infuse the service moment making it a part of a growing K-12 culture.

Pushing this envelope a bit further, I suggest that one of the best ways to get truly visible is to penetrate politics - the becoming of local leaders. We have physicians, lawyers, dentists, and such who pursue community leadership from a political/legislative arm - why not physical therapists? How else do you think we're going to demonstrate the value of our service (and knowledge base) at the media outlet scale?


Tactic: Encourage (if not favor) PPPT Affiliations in DPT Programs
We all know this to be true: students are generally considered free labor. Of course, effectively training, mentoring, instructing, and supervising physical therapy students can also be a labor intensive cost, if not associated risk.  The truth of the matter is that students add value by being generally free when it comes to labor itself. It allows for clinics to redouble their efforts in areas where they wouldn't without the extra body being present. Also, the value of students bringing the cutting edge ideas (not to mention, bright eyed passion) is something that is truly invaluable.

Having a student (or preferably, several students as in the physician/nursing model) consistently available to a private practice clinic will ease long term profit margins to the clinic, strengthening the clinics ability to survive and strengthen its position in the marketplace. This allows for PPPT owners to utilize some of that capital to fight the legal, political, and marketing battles essential to expanding & protecting market share (by the way, if you're not expanding, then you are shrinking). Additionally, affiliations en masse for this setting will foster a culture of entrepreneurial spirits rather than a quite common passive, "stay out of trouble once I get out of school" culture.

Having a mandatory private practice rotation will help the DPT student to learn about the business first hand, and, better prepare them for their own ventures in the future. It will act as a reality check paralleling the didactic experience which will grow a new generation of physical therapists - clinically sharp AND business savvy.


Some Closing Thoughts:
Physical therapy practice for the private segment needs to change. It also needs cooperative assistance from the rest of the industry at large. It does NOT help when "physical therapy" is viewed as walking in the inpatient hallways or  batting balloons in the air - do you really need to be a doctor for that? It is not constructive when sections of healthy skepticism turn into destructive criticism which attacks the already limited tools for which PT's can deliver their interventive measures.

PPPT has great opportunities in primary care, concierge home health (when not in clinic), community leadership, volunteering in the school systems for P.E., and even penetrating the world of politics. Even more so, PPPT has the same right & ability to turn into not just the owner of their own business - PPPT can and should look into becoming the owner of other businesses as well.

Our biggest barriers are legal and internal. While I have strategies to deal with legal aspects via strong marketing tactics - sadly - to date, I have no solution for a culture of unification. There just seems to be too much angst amongst our peers. Unity requires more than the presence of just strong leaders, it requires for a time and place where an entire industry's culture is ready to focus on what makes for a unified front rather than a divergent image.

Personally, I'm more than ready to step into a unified image and sacrifice my individual clinical identity for the greater good. This requires for all of us to collaborate with each other, not internally compete (See Nash Equilibrium concept). We have enough external competition pressuring our borders as it is; we must band together and defend those borders. Losing this battle is something we cannot afford; it will destroy our profession. Our selfishness, pride, and apathy are the enemy's greatest allies.

So I leave you with this:

"A single twig breaks, but the bundle of twigs is strong." - Tecumseh

Until Next Time, Yours Most Earnestly & Respectfully,

-Ben Fung

Management Tips (and Commentary): Skilled Nursing Rehab

Welcome to another episode of Management Tips, last post featured Acute PT. This time, we're going to talk physical therapy practice in the skilled nursing facility (SNF). I do want to first disclaim that this post is less organized as compared to my Acute PT post - it is more of a conglomeration of thoughts much as in the style of which Miyamoto Musashi wrote in his Book of 5 Rings (my next Martial Arts Musings post!) - if anything, I think for the many PT's working in geriatrics, this post will be much validation to know that you're not alone - AND - that there are, indeed, solutions!

Despite the financial weight and enormous revenue that "therapy" (I'll be complaining about this term later) brings to a skilled nursing facility, most SNF's use contract companies or vendors (internal or external) to supply rehab therapists in the rendering of service and billing thereof. The irony is that much of the time, "therapies" (again, later...) can easily account for half the revenue in your average SNF. Moreover, most residents that find themselves "skilled" for the stay tend to qualify for such metrics because of the "therapy" (ugh...) involved. So what's the beef? Why isn't "THERAPY" running the show?

Well, first and foremost, this is due in part to the fact that Medicare (amongst other insurances) views skilled nursing to be the primary service rendered at the (appropriately titled) SNF. Skill nursing is an extension of medical care and supervision by where a physician can remotely manage the now stabilized conditions of its residents post discharge from the acute hospital setting. "Therapy" (okay, I'll complain next time. PROMISE!) is seen as an adjunct; a component of the care provided at the SNF - despite the fact that in all realism, it in fact drives the care and discharge disposition for most residents.

The other challenge in the SNF setting is this: in the continuum of healthcare, the SNF is essentially the ultimately middle man of the entire system. The costs to run such facilities are great, fortunately, the revenue can be equally great. The profit margin is the challenge. And thus, many SNF's are operated heavily with accounting principles in mind.

So let's start here. First, most reimbursement models in the skilled nursing are based on RUG's (Resource Utilization Groups) which is nothing more than frequency of treatment and total minutes of treatment in any given time adjusted week. While strategic setting of RUG levels, COT's, and transition to RNA programs are very essential elements in managing rehab services in the SNF setting, all that content is more of an MDS talk... I'll just leave it at that. What perhaps is more important to remember is that maintaining high utilization is a pressure point that the healthcare administration (not to mention business office) will always be asking about. As such, some SNF programs utilize split treatments throughout the day to fulfill RUG levels or use modalities such a diathermy or NMES. Sadly, what you notice is a focus on the financial qualifiers and less on the clinical aspects of the care. The challenge? BALANCE.

The other challenge of managing rehab in the SNF setting is patient and workforce flow. Essentially, the SNF is a dumping ground for hospitals during key dates and seasons in the calendar year. Additionally, it serves as a type of restaurant business model by where you never quite know how many customers are going to walk through the door... and, you really don't know how many will walk out at any given time. In essence, it can quickly turn into a supply chain crazy place. You get a sense of what is coming down the pipe - sometimes. Most of the time, you just don't know and just hope that this year is much like last year. That is, of course, if you don't have well developed relationships with your referral sources. Ahhh, yes. It *is* who you know.

Strong SNF programs have fruitful relationships with local hospitals, particularly that of the case managers and social workers in said hospitals. More importantly, good SNF's will develop very close relationships with insurance case managers who ultimately approve the payment (and many times referral) of care. NOW we're getting somewhere. Since managing SNF rehab has more to do with managing flow of residents in and resident out than it does anything else, then it behooves all SNF rehab programs to be on excellent terms with case managers (both clinical and utilization review) who heavily influence the referred flow from the acute hospitals.

Once the flow of referrals are under wraps, the resident discharge disposition needs to be carefully regarded; primarily, the considerations of home, home with caregivers (which will only increase in the year of 2014), home with home health, or outpatient follow ups. Before things even get this far, we must remember that ACO's and managed care organizations alike stand to gain financially from decreased costs (aka. decreased lengths of stay and decreased utilization of services) but also stand to lose A LOT due to re-admission and/or sequelae. This is a narrow equilibrium for all tiers of the healthcare supply chain to consider. THIS is when things get into that discussion of what is "medically necessary" and what services are considered to be "skilled."

SO! Let's talk about "skilled therapy." (Yes. It took a LOT of discipline and several re-edits not to have that word before this moment.) Oh yeah... Get ready! The purpose of the SNF (from an economics standpoint) in the flow of healthcare is that such facilities present a less costly, less medically intensive inpatient care as compared to the acute hospital. If patients/residents do not require the intensity, attention, and skill sets present in the hospital, then the logical step down is skilled nursing. Below that would be home health, outpatient, and  finally, wellness/preventive care. So to backtrack just a moment, acute (with physician on site) stepped down to skilled nursing (with physician remotely, medically stable enough to be inpatient, but, not stable enough to be at home)... this line in the sand of inpatient vs. home is what "skilled" is all about. That basic question: can the services be rendered at the skilled nursing facility be replicated by lay people, say a caregiver or family member? If so, then you should be home. Assuming there's a reasonable assessment that being at home isn't detrimental to health/safety and wouldn't lead to readmission to a hospitals or emergency department (within 30 days...). If not, then a patient would find themselves safety (from a physical & medical standpoint) as a resident in a skilled nursing facility.

There's a singular problem: many times, what we find in the skilled nursing setting is that many things are simply NOT skilled. We already saw this happen in the industry back in the 80's and 90's with outpatient services. If you're ears are ringing the way mine are, you heard it correctly: cost, Cost, COST! How to contain it, drive it down, and, how to do so and still develop good revenue and margins without blow back from poor outcomes, beneficiary dissatisfaction, and regulatory penalties?

The cardinal problem is that skilled nursing (as with any area of the healthcare industry) is still a business at the end of the day. There needs to be more dollars coming in than going out. SNF's stand to gain to keep residents as long as possible; the people paying (insurance companies) stand to gain to discharge as soon as possible (assuming readmission is not a likely event). This will always be a tug of war until health systems begin to share costs and outcomes across all practice patterns (HUGE other discussion I should hope to write upon in the future).

But, I do digress, what about the "skilled therapy?" Well first, everyone knows that nearly all residents/patients/family members consider "therapy" to exist as physical therapy. Occupational therapy is apparently also a form of physical therapy. Speech therapy (as usual) is in its own world, as perceived by the consumer. Oh, yes. And all rehab staff are "therapists." THIS IS TERRIBLE! Not only does this completely dilute the value of all disciplines, the degrees they earn, and clinician licensures, this basically tells us that there is nothing "skilled" going on! If consumers can't tell the difference... well, then what's the point? If the idea of skill rehab is to quickly and safely return residents back to their homes (at levels where premature hospitalization is avoided), there are questions that are begging - questions such as: (1) Does it really take a Doctor of Physical Therapy to perform a maximal transfers of two persons for a medically complex patient with a medical diagnosis of pneumonia? (2) Is the supervised/contact guard/minimal assistance level of gait (without need for neuromuscular facilitation) truly a skilled event? Something that a caregiver, family member, or nursing assistant couldn't do? (3) When will SNF's begin to build relationships with insurance carriers to define solid, concrete, objective criteria AND time tables to discharge disposition? Such as the basic: No one goes home without 24/7 care if a resident demonstrates a Tinetti POMA less than 19?

Truly, what would be a better use of "skill" would to high levels of case management and case delegation from a supervising physical therapist to the maximal amounts of assistants. Ideally, state restrictions on the number of supervised assistants and aides need to be severely liberated. Not only would this make costs more manageable, this would make the level of care delivered realistic with the level of skill required at this setting. After all, most of skill nursing rehab isn't exactly the ICU; it isn't exactly a large caseload of dry needling, spinal manipulation, complex wound care, or neuro rehab... is it? I mean, let's be honest here. I'm not belittling SNF rehab, at this moment, I'm a director of a SNF rehab program. What I AM saying is that the utilization at SNF's need to be carefully reviewed and restructured for future sustainability and justification. Enough said (for now).

Speaking of structure. One of the biggest management tips I can list is to build infrastructure. All too often, our poor and overworked director of rehab (DOR) is the centerpoint and corner stone of the entire operation. If the DOR is out, the department loses half of it's operational strength. Sound familiar? Additionally, turn over in SNF's are tremendously frequent. There is usually an anchor team which has stuck around for a while; there is also a regional population of wandering clinicians picking up any hours they can find at any number of facilities. So how can one build infrastructure? Hint: See my paragraph above. With revisitation of skill set and appropriate labor utilization, there is much to be said about the cost containment and performance metrics that corporate will impress upon any program. This, of course, takes much time and legislative development.

Nevertheless, there are still ways. First, identify primary or lead clinicians for all disciplines. Identify a 2nd in command and a 3rd in command from those leads in lieu of the DOR. If there is an outpatient program attached to the SNF, be sure to develop an outpatient coordinator position. A rehab aide/tech/secretary is VERY helpful in any program. Since most DOR's are fixed costs, it stands to reason that the process of scheduling & staffing (which usually takes way too much time for most facilities) can easily be delegated to a non-licensed staff member - much as outpatient clinics operate. Also, this will free up the DOR to see more patients and get increasingly involved in the case management and direction of care throughout the facility. Finally, EVERY staff member needs to be empowered to tackle the many service recovery opportunities that exist in the SNF setting, and, be intimately aware of how payer source and treatment frequency are related to the daily operations.

So we've covered the elements of business relations in SNF Rehab as well as operational infrastructure. There is one more aspect I'd like to discuss in management tips for SNF Rehab; this is the topic of employee engagement. Again, I'm going to ask that we be honest with ourselves. Employee engagement in outpatient settings, acute rehab/inpatient neuro, and largely even in home health is fairly organic. There is enough stimulation with a day to day "I feel like I've actually helped someone" in the mix that engagement isn't a risk factor for those settings. However, SNF Rehab is a high risk setting where clinicians can easily and very quickly burn out without strong levels of staff engagement. Most markets try to make up for this by paying SNF clinicians the highest in comparison to any other setting available; more money to tolerate more nonsense and to keep from complaining. However, we all know, money isn't everything.

My best advice when it comes to employee engagement in the SNF setting is to empower the staff to three, typically easily achievable, facets of practice: (1) take ownership of the business. This extends to things such as the day to day, customer service & recovery, understanding what payment models do what and how that affects their own practice. (2) Take ownership of a specialty. Have one clinician be the seating/positioning specialist while another specializes in neuro and yet another in wound care, etc. (3) If the facility/community is agreeable, organize regular inservices by which the rehab staff teaches the community staff about rehab, ergonomics, and workplace safety - we are teachers of health, after all.

Some Closing Thoughts
SNF Rehab is under high levels of scrutiny by all sides. Clinicians are questioning the ethical stance of the practice patterns that have been laid and grandfathered in from the past. Payer sources are questioning the utilization. Customers are skeptical about the quality of care and the lengths of stay. Additionally, since healthcare is going into a cost containment model to achieve best outcomes through the lowest cost, SNF utilization will only increase as a measure of early discharge from the acute hospital. However, this same model will only cause shorter lengths of stay in the SNF. While residents can easily readmit themselves to the SNF without going back to the emergency department, this doesn't change the fact that insurance carriers will be pressuring facilities for early discharge - AND - eventually ACO's/Medicare will be more readily auditing high RUG levels and longer than average lengths of stay. Two words: PEPPER reports. Oh yes, one more thing, this only will unfold as such if SNF's actually demonstrated the value of their "skill" - if the outcomes are no different, things will simply (as they are beginning to) heavily shift into home health and just bypass that middle man who may cost just a little too much.

The other aspects of SNF Rehab management include employee engagement, developing strong relations with hospital & insurance case managers to assess supply chain flow, and building sound operational infrastructure amongst the staff. Personally, I find that the building of infrastructure is the most difficult piece to solve. Most rehab companies in the SNF setting impose some incredibly high productivity standards to their staff. Most of the staff just keep their heads down and run between treatments while they document at point of service to manage the standards so that they aren't written up. This is, again, a terrible way of managing staff since all they do is live in fear they'll be written up for something they can't actually control. Instead, if managing costs and operations is the goal, it is best to start backwards. As I mentioned in the middle of this post, really reevaluating what is "skilled" is a good place to start. Using this lever to move the needle in the realm of licensures in liberating who/how licensed clinicians can supervised under them will really be bottleneck for realistic solutions.

In any case, for the time being, SNF Rehab management is also waiting for healthcare changes in the year of 2014 to fully reveal itself. It's a rather unsure time in that no one quite knows how the market will behave once the legislative climate settles down. In that regard, managers and company executives need to bulk up for any possible looming storms. Acting like the situation will take care of itself is simply asking for trouble. The proof is in the many SNF's that are already closing PRIOR to the full force of the 2014 changes.

Since I like to close with positive thoughts, I will highlight that the best business move for SNF's is to developing very strong relationships with the case managers who determine hospital discharges as well as those in utilization review who determine payment. Case managers that hear that your facility's rehab program is the best; best staff, best results, and most economic will favor you against competitors. This reputation will also help engage the staff at large and serve to bring more positivity to the equation. And, in this current economic climate, programs can use all the positivity it can hang on to. It's up to our managers to find it, cultivate it, and retain the momentum. For, in the midst of uncertaining, a strong team cohesivement and positive dynamic is the best weapon you have to encourage a culture of stability.