The future of the long-term care industry is about as predictable as the stock market—and, like the market, when it comes to forecasting, there are bulls and bears. But the volatility that affects the industry includes not only economic conditions and corporate management, but also the shifting priorities of Congress.
In the mid-1990s, the long-term care industry experienced its version of a roaring bull market, complete with high profits and corporate buyouts. Larger rehabilitation companies bought out many smaller companies with skilled nursing facilities (SNFs). Salaries and signing bonuses for rehabilitation therapists, including speech-language pathologists, rose to an all-time high. At the same time, rumors and reports of abuses, such as billing for services to patients who could not benefit from them or providing an excessive number of visits, became more widespread.
Then the bottom fell out of the industry with the passage of the Balanced Budget Amendment of 1997 (BBA). The budget law replaced the existing payment system in SNFs with the Prospective Payment System (PPS), based on a per-diem payment directly to the facility. When PPS was implemented in nursing homes in 1998, many SLPs lost their jobs and migrated to other settings. Those who remained in SNFs faced greater productivity pressures and the forced limitation of services.
The job losses caused by PPS are reflected in ASHA’s 1999 Omnibus Survey. Of the SLPs surveyed who worked in SNFs, nearly 30% reported that they had lost their jobs. That percentage is twice as high as job losses suffered by SLPs in any other setting listed in the 1999 survey.
Some of the nation’s largest rehabilitation companies that relied on Medicare as their main revenue stream went from lofty profits to crushing debt. Two of the biggest—Vencor and Sun Health—declared bankruptcy and have since reorganized.
PPS and the $1,500 Medicare cap—which limited reimbursement for Part B outpatient services—hit with a one-two punch from mid-1998 through early 1999. Together, they had a chilling effect on the delivery of speech-language pathology services to residents in long-term care facilities.
Paul DeVreugd, an SLP and current president of Therapeutic Resources in Detroit, MI, weathered the storm and recalls its impact.
"When PPS hit, most facilities went from offering speech-language-pathology services on a full-time basis by in-house staff to offering minimal services," he says. "I lost 60% of my rehabilitation therapy staff to non-health care settings."
Congress did ultimately put money back into the Medicare system for SNFs, and ASHA helped lead the successful effort to stop implementation of the $1,500 cap. But it was too late for the SLPs who left long-term care settings for new jobs in schools, hospitals, or private practice.
Need for Dysphagia Services
For the frail patients usually seen in nursing homes, the loss of qualified SLPs meant a decline in the quality of care—in particular, in the delivery of dysphagia services. The drop is shown in ASHA’s 1999 and 2000 Omnibus Surveys, with a slight decline in the percentage of SLPs providing dysphagia services reflected in the 2000 survey.
A high level of skill and training is required for professionals treating swallowing disorders, which can be life-threatening for a patient.
"You can’t do direct harm to patients by treating them for aphasia or dysarthria, but if you don’t make the right call with swallowing disorders, your patient can aspirate, leading to severe medical complications," says DeVreugd, noting that many of his clients are candidates for dysphagia services because of shorter hospital stays.
In some cases, occupational therapists were asked to deliver services, which he views as an unacceptable solution.
"SLPs have carved out our niche in dysphagia in the last 10 to 15 years. If we don’t tightly define our role, we do risk the loss of some of our scope of practice," he says. "I don’t think that we can share this service delivery, for the safety of the patient."
Recruitment Drives Underway
With Medicare funds flowing back into long-term care and the $1,500 cap still under moratorium, some of the nation ’s largest rehabilitation companies have launched recruitment drives to attract qualified SLPs back into the industry.
Certainly, demographics point to a growing need, with the first of 77 million baby boomers turning 65 in 2010 and the number of Americans 85 and older expected to double by 2030.
In July, Genesis Rehabilitation Services hosted a meeting of clinical leaders from companies providing rehabilitation services in long-term care settings, which ASHA attended. Key discussion topics were staffing, recruiting, and the provision of dysphagia services.
"To rebuild and retain qualified staff in long-term care, we must look at protocols, policies and procedures, and support for professional development, " says Arlene Pietranton, an SLP and ASHA’s chief staff officer for speech-language-pathology, who attended the meeting. "Are companies encouraging people to belong to special interest divisions and other types of networking lifelines? Do they have programs of integrity, or are their operational processes overly influenced by the bottom line? That’s what we asked the industry representatives.
"One of the opportunities and challenges here is to make the long-term care arena a preferred practice place because of the integrity and quality of services that occur there, and not just because of financial bonuses," she adds.
Of the eight large rehabilitation companies represented at the meeting, two responded to queries from The ASHA Leader concerning their company’s prospects and current recruitment:
- AEGIS Therapies , formerly Beverly Rehabilitation, is a contract organization of Beverly Enterprises. According to Susie Almon-Matangos, clinical director of rehabilitation operations, AEGIS currently has openings for 80 "full-time equivalency" positions for SLPs and 60 "casual" positions available. Dysphagia services are "critical care needs" at AEGIS. Since PPS, all clinician positions have changed from salaried to hourly. Growth is occurring in Alzheimer’ s care, and there is an emphasis on clinical training and outcome data collection. "We would like to hire seasoned SLPs," she says, adding that, for new graduates, a CF mentoring program is available.
- Genesis Rehabilitation Services handles more than 600 long-term care contracts in the Eastern United States, and the company has seen a recent upturn, says Gary Pezzano, vice president for clinical practice. He estimates that Genesis now needs "about 50" more SLPs, and notes that further aggressive growth is planned. The company offers salaried positions—"I think we’re one of the last," he says. Staff "have to understand reimbursement and what the facility is capable of in terms of admissions." He adds, "It used to be that a facility could afford to accept any admission, but now you have to be clinically set up to take care of sicker patients." The company offers in-house online training and is developing a "master clinician" program.
Weighing the Job Decision
Although the outlook appears brighter for SLP jobs in nursing homes, DeVreugd urges members to educate themselves about the long-term care industry.
As in other settings, self-advocacy helps build your caseload, he adds. "I filled in at one facility, and there were two people on my caseload. I talked to the dietician about my services and, within two weeks, I had 15. That’s one way SLPs can change a part-time position into a full-time position."
Overall, DeVreugd believes that "the need is great and the prospects are very good" for growth in the industry. He notes the expansion of rehabilitation services in SNFs that results from shorter hospital stays, adding, "The bottom line is, facilities need staff to provide services, even if they can’t quite provide the money they did before PPS."
SLPs who have relocated to schools or other settings need to consider their personal interests and goals, and to compare their salaries, benefits, tenure, and job stability to possible jobs in long-term care. Some may prefer the greater stability of the educational setting, DeVreugd says, but acknowledges that long-term care has its rewards.
"In the last two weeks, I weaned five people from the vent and the trach and tube feeding," he says. "This lengthier rehabilitation process couldn’t have happened in the hospital—doing the feeding trials, getting them to talk. Now all of them will be going home. That’s very satisfying."