June 4, 2018, Maggie Flynn, Skilled Nursing News - With the advent of the Center for Medicare & Medicaid Services’ (CMS) new Patient Driven Payment Model (PDPM), rehabilitation and therapy in the skilled nursing space has come under intense scrutiny.
When CMS introduced PDPM in late April, it touted incentives to treat the needs of the whole patient. One side effect of that focus, however, is to eliminate therapy minutes as a driver of reimbursement. As a result, rehab and therapy companies will have to provide solid outcomes in less time.
But expectations for rehab have been evolving well before PDPM was a twinkle in the agency’s eye.
“We saw a spike right about 2011, 2012, 2013, where a lot of people started coming to us with this request [for rehab renovations],” Grant Warner, principal at D2 Architecture in Dallas, told Skilled Nursing News. “And it’s grown from there.”
Evolution in the space
The architecture firm THW Design in Atlanta has also seen an increase in physical therapy (PT) and occupational therapy (OT) suite renovation that predates PDPM. That’s in part due to what’s expected from the coming wave of baby boomers, THW senior project manager Melinda P. Avila-Torio told SNN.
“What we’re seeing is a lot more orthopedic injuries than any generation preceding them,” she said.
In addition, equipment in the rehab space is evolving, both Warner and Avila-Torio said. Some of the equipment is getting bigger, while some pieces are increasingly designed to be mobile, Warner said. That becomes a consideration when designing a space.
“The physical therapy spaces themselves that are more open are getting bigger,” Warner said. “And we’re seeing a big push in water therapy.”
Another factor is the population that will be using the facility. Most of the renovations Warner discussed involved case studies of continuing care retirement communities (CCRCs), where the rehab is offered as a benefit to the residents on different points of the care spectrum.
But Ozanam Hall, a skilled nursing facility in Queens, N.Y. with more than 400 beds, had approximately a 90% wheelchair-bound population. It’s now in the planning stages of upgrading the facility’s rehab gym, which currently is about 2,000 square feet. The expansion plan involves almost doubling this size.
“The radius need for that PT and OT community is more constrained than for any other user group,” Avila-Torio said.
At the moment, every area of the rehab gym has to do “triple the work” because there’s currently no single-purpose zones, she explained. So in addition to figuring out how to get residents in and out easily, THW is also looking into enhancing storage solutions for the space.
The designers additionally took over an administrative suite that was no longer needed across the hall from the gym because the building envelope can’t be expanded; Ozanam was built in the 1970s, and as a result the arrangement is akin to a typical office building, Avila-Torrio said.
“I think this PT-OT area has been here ever since the building was constructed,” she observed. “As soon as you walk through the door, you’re greeted with what I’ll call a command center… when you go right in, it’s crowded.”
Navigating new incentives
Even before the new payment model, there were reasons to improve rehab in SNFs, David Dillard of D2 Architecture noted.
“The incentives seem to be in place to invest more in the rehab wings of existing communities because of the penalties hospitals are facing for readmissions,” he said.
One of the benefits of PDPM is that clinicians will be able to prescribe new combinations of therapy, according to Lou Ann Soika, senior vice president of customer relations and strategic development for Genesis Healthcare’s (NYSE: GEN) rehab arm, Genesis Rehab Services. That can include individual, group, and concurrent therapy.
D2 Architecture, in addition to seeing demand for bigger spaces, has also seen the need for smaller, one-on-one therapy spaces. As a result, the firm tries to make the gymnasiums it designs more flexible, using half-walls, dividers, or movable pieces to help with privacy, Warner said.
The costs of the improvements can be high. Though Avila-Torio could not give a specific figure for the renovations at Ozanam Hall’s rehab space, she said it is “a six-figure dollar investment.” Structural constraints are the biggest hurdle, especially if dealing with a single-story building where “almost everything is load-bearing,” Warner added. Regulations and zoning can be an issue as well, especially for older buildings.
But there are ways to update even old buildings, especially in terms of using phases of renovation, Warner stressed.
“We can’t build new [buildings] fast enough, and we can’t afford to build fast enough to meet demand,” he said. “We have to find clever ways to meet demand.”