Welcome to the American Occupational Therapy Association's Checking the Pulse blog. My name is Stephanie Yamkovenko, and thanks for reading the blog.
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Update October 15, 2014: AOTA worked with APTA and ASHA to create this consensus statement on clinical judgment.
For many of us, the word productivity has new implications in the workplace.
Productivity may be linked to maximizing delivery of services to impact reimbursement, but increasing health care costs, diminishing payment, and an emphasis on efficiency have created a challenge for occupational therapy practitioners who have to manage and provide a higher volume of services, and related patient care responsibilities within the confines of a typical workday.
For some of you, facility productivity standards are causing you to do a lot of work off the clock and, in some cases, to confront ethical challenges.
AOTA is aware of this issue and has been working to develop our own educational materials as well as collaborating with other therapy provider organizations to develop more resources for you.
Our ethics advisory opinion on productivity, reimbursement, and billing provides case examples and discussions to provide guidance in addressing ethical challenges related to productivity. Read it here and share it with your colleagues.
Please share your stories with us about how productivity is affecting you and your clients. AOTA will use your experiences to help us in developing future materials. You can comment on this post below.
I am so happy to express myself on a professional media website regarding productivity and expectations by facilities. I work for a major health care facility system. It is an "unsaid" expectation that we therapist give as much "free" time as possible in order for the company to make ends meet and be profitable for growth. All at "our" / therapist expense.
Last year I lost over $5000.00 compared to the year prior, due to these expectations. I'm am hourly waged therapist and they resist making us salary, even though most of the other facility therapist are salary. I wouldn't mind using low need census and punch out early, if I knew my pay check would be consistent.
In a given week I estimate giving this company free time of my services at an amount of 8 to 10 hours. That is not the time I punch out early and have to use up my PTO. I have had to use so much PTO for low need, I have minimal to no hours for sick, vacation or even dream of time off/vacation.
I've been an OT for 10 years and with this company for 4 years. And I see the health care facilities expectations going up and up. 90% and above productivity seems to be the standard. With these expectations puts ethical means at high risk, for those you are economically challenged themselves. I would hope most therapists are honest and ethical with their billing. But I believe these pressures may be becoming to great.
Why is it ok for health care to put these demands on individuals. Facilities and companies new trend is "patient satisfaction" and evidence based". Where is the evidence of therapist satisfaction? Someone asked me, if I would recommend a student pursuing an OT career and I actually hesitated.
Going broke OT.
I am very pleased to find a place in my professional organization that will allow for objective comments regarding productivity. I worked for 15 years at a large hospital in a metropolitan area, with decreased demands on productiivty, mainly due to ethical leadership within the department.
I have recently moved from that position and become a traveler, which has introduced me to the SNF area of practice. Wow. Talk about an eye-opening experience. I have been to 3 SNF's on 13 week contracts and 5 more for short term per-diem coverage. The pressure to perform is very high and I have witnessed more I can count, therapists documenting during their meals, before and/or after they clock in. (not to mention buying their own supplies - ie: bleach wipes, scotch tape, gloves, patient education handouts ...)
As I have practiced 15 years in Inpatient Acute Care settings, I have not been following the SNF practices. I admit, I'm angry that there is a system that dictates the amount of time my patient "needs" in the SNF setting, whereas, in the Inpatient Acute Care setting, I apparently am able to use my professional clinical judgement regarding how much therapy my patient can tolerate/benefit from.
The pressure to "pick up" patients on caseload is abit maddening as well. Patients that are severely demented, non-ambulatory, dependent in ADLs, yet the head of Nursing or the MDS coordinator informs us "this person has to be picked up due to a decline in function." I read the patient's history and this person has not declined, they have simply demonstrated behavior due to understaffing of nursing care. !!!
Who does CMS think has the clinical judgement to evaluate and write a plan of care for patients? I would hope that someday SOON someone would walk a mile in my shoes, really see the insides of the SNF setting and then increase the qualifications for SNF Administrators and SNF Nursing Management.
I still LOVE patient care and I've met some AMAZING therapists, but I wonder how much farther this productivity demand can continue without an increase of therapist burn-out, illness, or worse. Bless all of us out there that love OT.
I am an OT at a CCRC and am expected to be 80% productive. I hear that is good compared to other companies, but my coworkers and I struggle to meet 80%. We all work off the clock at least 4-5 hours a week and lose approx $8000 a year. We are expected do complete screens, go to meetings, and travel to campus destinations that take at least 10 minutes round trip. Also, after working at my facility for 4 years, I get stopped ALL the time with questions from staff or by residents just to say hello. I feel like if you are ethical, it is practically impossible to meet the productivity expectations of most companies. We now have ipads, and I am very good at point of service documentation. However, I still struggle with 80%. I have a hard time doing weekly notes and updated plans of care in front of pt's. I also struggle with keeping up with all the unexpected discharges (when pt's go to hospital, etc.) and I have to complete the paperwork after they leave. My company gave everyone a 5% pay cut last year and has never given any raises to my team in the past 4 years. It's stressful! I wish we could all be salaried.
How is it that Juan has the time to think about the ethics of his co-worker? As OTs we are constantly being put in situations that require us to compromise our ethical behaviors, or wind up not being "productive." enough. It is our patients that suffer when we are told to do "point of service" documentation. It means spending less time in meaningful tasks engaging with the patient, and more time having a patient either sitting in front of you "resting" or engaged in some activity that is less meaningful so that we can document and stay within "productivity". How is less time with the patient helpful to the overall rehab of the patient? After working in several different SNFs I have come to the conclusion that long term care patients are commodities, used to build revenue, with screens the method by which patients get rotated onto rehab every few months, whether they need it or not. I understand the concept when someone goes out and comes back to their facility, however, there comes a time when a 90 year old should be able to live out his or her life without being put on a rehab program because the stats are low, or because reimbursements have decreased. I don't enjoy being "creative" with goals or treatments in order to keep my job. I need AOTA to be a liason for OTRs and COTAs and explain to these big rehab companies that they are making it impossible for us to do the job we love to do ethically, and without feeling depressed at the end of each day. We are being encouraged to engaged in practices we distain in order to abide by their demands with unwritten rules and "understandings " as to how things need to be in order to be profitable. I don't need information on where to look for guidance on ethics, Most OTRs and COTAs are extremely ethical which is why we put in so much time without getting compensating for all that we do. Please AOTA, tell these companies to stop sucking the life out of us. They are the ones with an ethics problem.
I like to think I do what's right for the patient. I work in acute care and I feel like I really have to prioritize what the patient needs since I only have a limited time. I feel we are held to PT standards but we're a different field. It takes longer to do ADL'S and I don't think that is reflected in the productivity standards.
With that said, I've worked SNF and IP Rehab where you were required to get a certain time for each patient so the facility can get paid a certain RUG level. Here you are treating a 93 year old patient for 90 minutes who can only tolerate about 10 minutes. That is the type of situation that angers me.
I understand we need a standard. But, I think the standards are too high, fueled by people trying to make money(.Who makes these standards?) The patient should come first. We should be trusted to use our professional judgment to treat the patient for what they need in an amount of time they can tolerate.
I agree completely with sgoldbe1 when they say that OT's do not need more guidance on ethics from the AOTA, but what we need is for the greedy profit-focused rehab companies to learn their own ethics. I've been an OT for 11 years. I started off at Johns Hopkins Hospital then left to become a traveler & later settled in Seattle. Since then I've worked at nearly 50 facilities across the country... Hospitals, Inpatient rehab, SNF/ALF settings, school based OT, & home health. What I can tell you is that unless you work in the schools or the rehab company is a private non-profit facility, which rarely ever exists anymore (I live in Seattle, WA and there is only 1 remaining), you will be pushed to meet some magical productivity number that you literally can't meet if you stop to urinate twice in your day and actually take a lunch break. Of course, the person(s) setting these ridiculous expectations are not therapist & are people who sit at a desk all day pushing papers and looking at numbers (typically they have business school backgrounds and don't even know what OT is!). Sadly, I have seen more OT's than I wish to admit forced to jeopardize their ethics and work off the clock... many hours off the clock! I hear more and more therapists talking about burn -out and I'm not surprised.
As a contractor OT in a SNF, I've had several experiences where I chose not to pick up a patient but was handed back my eval and told "you will pick them up" despite the fact that nothing had changed in their function. In one SNF, I was given a 93 year-old patient for 75 mins. About half way through the session the patient had a major seizure and was transported to the hospital. The rehab directors response when he heard this was, "S***! You better hope he's admitted or we're screwed & you're going to have to find a way to get the rest of those minutes because it's his last day."
Finally, this past January I officially hit my limit when I interviewed for a new home health OT job. The way they described their practice wasn't sitting well with me so I attempted to press the issue of ethics with the head person running the interview (who had previously been a therapist). Her response, "You need to just learn to play the game and go about job." Needless to say I did not take the job and I have decided that I'm done playing the "game". I didn't become an OT so that I could bring in bigger revenue for these profit hungry companies or so that I could be forcing therapy on people who don't need it. I don't believe we are doing a service to anyone working under these conditions. Currently I'm pursuing a new career.
I have worked at several SNF's, in the past 6 years, hoping that one was better than the other in terms of ethics of billing practices. I love working with the geriatrics population. I do all I can for my patients, however at the end of the day, it comes down to how much money has my OT license made for the company. I have had co-workers reprimanded and threatened to lose their job for discharging a patient early. Because of all of the shenanigans, I have swore off working in another SNF. I feel that the therapists professional opinion is not respected and other non-therapists are making the decisions for us. Who are they to tell me how to do my job? The phrase that irks me the most is "Think outside the box." I feel that it is time for these companies to "think outside the box" of profits and show some appreciation and respect for the therapists they hire because we are trying to do what we were trained to do and they are sabotaging our efforts.
As we all know, ethics is at high risk, as well as burnout. I am a new COTA this year, and I am very disappointed that productivity is the driving force in rehab healthcare. I cannot come across one therapist that works in a SNF that has never worked off the clock. Working off the clock is ILLEGAL; it is more than an ethics issue and SOMEONE needs to begin standing up for therapists--I would hope that it would be AOTA.
I am a 2nd year COTA student who just had his eyes opened to what 90% productivity in a SNF looks and feels like. Working off the clock, no breaks, lunch on the run and pressure to keep clients in therapy seems to be the norm. My field work supervisor drilled rather than taught and the pace was so fast I couldn't actually learn anything. Could the fast-paced world of productivity and profit be affecting our field work teachers as well? What kind of new students will this produce? I'm considering dropping out of the program altogether after today. With Obamacare underway, I can't imagine this situation will improve any. I can't begin to describe how saddened and disappointed I am.
I have worked for a major rehab company, which has been a main sponsor for AOTA conference. I have always though aota was turning a blind eye to these unethical practices due to sponsorship, so I am glad to see this blog post! At our company we had to be close to 90% productive. If we left early due to low caseload we were not allowed to use PTO to make up for the hours.
Anything above 80% is highly unethical, due to the nature of the job there is no way to meet this without lying about time in facility or by treating concurrently and billing for individual. Time spent discussing client care with nursing, doctors, family members takes a lot of time out of the day. Also things such as bringing a client to the bathroom for ADL. If they are a falls risk they can't be left unsupervised and you can not bill for this time, Also, during meal times unless you have feeding or positioning goals for a client you are going to have at least and hour between breakfast and lunch in which you clients are unavailable.
Not only are productivity standards ridiculous, but so is the need to meet RUG categories and the push to pick up Medicare B patients when the census is low, whether they need OT or not.
My two most disturbing incidents with my precious company are as follows: We had a client who was a danger to herself and to others, who was going to be sent out to the hospital, my area manager told me I should tell nursing to keep her at the facility for 1 more day so we could meet the RUG category! Obviously I did not pass this message along.
I was covering at an ALF, census was getting low and the director gave me a name of a client to pick up, claiming " she's on our last resort list of patients we pick up if things get really low." I also was questioned numerous times about discharging clients early ( all of whom were seen for over 30 days,who had met their highest functional level).
In school we learned to be great therapists and to do the best for our clients, with a main emphasis on ethical behavior and client centered treatment. Unfortunately these big rehab companies have absolute no concern for giving client centered treatment and encourage unethical practices. Money is all they care about. It really is such a shame as I love my job and my clients, however I am turned away from this field due to the unethical expectations of these big companies. I believe "in house" rehab is the way to go. Makes for happier therapists and a better connection to facility staff and clients.
I am an OT student who is only 5 weeks into the first semester of my graduate school program and I find these comments greatly disheartening and concerning.
Thank you for the comments. They are very helpful to us as we continue to work on creating resources for you. The newest resource is this consensus statement that we developed with APTA and ASHA: www.aota.org/.../Consensus-Statement-AOTA-APTA-ASHA.aspx
I would be interested in a blog that discussed what I call the de-professionalization of OT. I have been a therapist for over 30 years and see a serious downgrading of our profession by insurance companies, employers, educational health care institutions, contract agencies and therapists themselves. I worked for one employer who told me (with a gleam in his eye) that his company was experimenting by offering less then market rate pay to therapists to see if they could get a staff to work for them. All you have to do is look at the lackluster rate of reimbursement over the last 20 years to know that what I am saying is true.
I love OT too. But OT's beware - our profession badly floundering. I think we need blog that tells the truth about how we are getting squeezed and some things we can do about it. Does anyone know of one?
I am very happy to see that AOTA has taken this topic seriously. I work for a " big rehab company" who is taking over all other companies and is also expanding its business overseas to " survive in the healthcare business". At the end of every day we get a productivity number and as OTR's we are required to keep it at 82 percent. It looks manageable compared to what other companies are asking for , but I am the only R in a 80 bed facility and I find it very difficult to do so at times. To make this more complicated, PCH and productivity are two different things! We don't see how the company calculates the PCH but we are supposed to maintain it over 82 percent. Pt evaluation time, screen times, meetings ,documentation for progress and recerts don't count towards the PCH. Frankly speaking , it is impossible to maintain your PCH unless you are billing for everything. Sometimes we have to take to our manager daily as to what we are doing to maintain our PCH if we were low by a point the previous day. It is like we are some robots and let me tell you- they don't care! They ask for your 'opinion' but at the end of the day it's the number. Now they have come up with a new system to push for our PCH - point of care service! Which is ridiculous and stupid and should never be implemented as most of our therapy is hands on. Our clinical director even quoted a note Aota practice guidelines that it is our " professional and ethical duty" to do point of service.
Personally , I am absolutely burnt out in my place and feel like no one understands or values my opinion as a clinician. Manager will ask to pick up patient for a week or so to " train the aides in correct positioning during ADL's" for a LTC patient who is D for all her ADL's and has been in the facility for over 5 years and multiple RNP programs in place. It's all for the money and we have to pick up patients that fall in the facility due to poor nursing care and not following the RNP program that has been set multiples times before. Anyone else out there who feel that RNP's are a joke?It is very very frustrating to say the least and I often wonder - Did I go to OT school for this?. What has our profession come to in these money making rehab setting who consider elderly to be a commodity to make money. Are we just a glorified CNA- coz all they care about are ADL's ? There is immense pressure from your supervisors if we don't pick up med A's or Med ' B pt. I can go on and on about how horrible it is to work in an SNF and all the above comments are true and have experienced very single one. At times I though of changing my career, however I am moving out of this setting soon. I feel grateful to see that I am not alone ( at time a I feel I don't know what therapy is anymore )and there are open forums where others can provide support and bring out the truth that goes on in these setting.
Ellen Kolber- I was looking for one myself and did not find any.