Burnout In SNF Rehab

I certainly am not the end all be all authority on this topic, but having worked in several Skilled Nursing Facilities (SNF) for the past almost 3 years both as a full time therapist and as PRN employee I think I've gained at least a little insight into this work setting. And let me tell you...it sucks.  It sucks to be a patient and it sucks to be a therapist. This information is based on working in SNFs from 2015-2018. I am now transitioning away from speech therapy due to burn out, but there is supposed to be a brand new reimbursement system rolling out for Medicare in October 2018 which will be changing a lot of the policies written about in this blog post. I hope it will change things for the better. 

Here's why it sucks to be a patient in a skilled nursing facility. If you fall and break your hip and go to the hospital you may need some rehab. The hospital wants you out of there ASAP so if you cannot go home...welcome to a skilled nursing facility!  Paid for by Medicare for up to 100 days. If you are really sick and cannot participate in therapy, tough luck but you WILL be participating because that's what's paying your bill. If you consistently refuse to participate in therapy, or if you don't show progress in therapy, you can't stay. The problem with this is that the people who NEED to stay are usually the sickest people, who don't show as much progress.  Or sometimes patients don't have as much family support and can't afford the daily care they need at home while they are recovering.

And you are not going to be participating for just a little bit, you are going to automatically get therapy 5 or more times a week across various disciplines (PT, OT, and ST). If the therapy department has their way, you will not receive 721 minutes each week and you sure as hell will not receive 719 minutes. You will receive exactly 720 minutes. Why? The government made it up. Reimbursement categories based on minutes are called RUG levels.  Now, In la la land therapists are supposed to assess a patient, figure out how many minutes of therapy is truly needed,  provide that amount, and then get reimbursed appropriately for whatever Rug Level that was provided.

What happens in real life is that everyone is slotted for 720 minutes no matter what. You don't really need that much? well.....let's do some bullshit treatment to get you there anyway. You need a lot more than that? Tough luck...we can't make the time for you because we don't get paid for it. Therapists are told from one side of the corporate mouth "oh 720 minutes is just an estimate" while also being told "Tighten up! why are you one minute under or over!?". Corporate will tell the therapists to back down the minutes or bump up the minutes to get exactly to the totally arbitrary 720 number.

To play devils advocate for a moment, I do obviously understand that the patients are in an SNF to get therapy. If a patient truly, truly cannot tolerate 720 minutes each week, companies DO actually allow therapy to be provided at a lower level on a case by case basis...as long as it doesn't happen "too often". But no one gets anything higher. 720 minutes a week breaks down into around 144 minutes a day (around 2.5 hours per day). When it's put in that context, it's not that much out of a patients day and sometimes for the rest of the day there's not much else for them to do. For people who need that amount of therapy it works out OK. 

The problem comes when patients really don't need it, or can't tolerate it. I have seen many people begging to go back to bed. Or patients basically falling asleep on a stationary bike while in a "therapy session", while a therapist is reading a magazine. I've seen patients who are very sick and really cannot tolerate this much therapy pushed into it and asked multiple times a day if they've changed their mind and would like a little more. And how many times a day did I hear a therapist mumble "what am I supposed to do with this person for 75 minutes?". This leads to sub par therapy in my opinion.

Perhaps the more annoying part, in my mind, is that there are some people who could tolerate and even greatly benefit from MORE therapy time. And yet are not able to get it because of the crazy RUG system. 

In my experience OTs and PTs are highly encouraged to pick up everyone, each for about 75 minutes a day and pretend it is always appropriate. Unless speech therapy is involved, then instead the appropriate minutes are magically reduced, to "make room" for speech therapy. It's not supposed to happen like this. A PT, OT, and ST should have the option of evaluating a patient and saying "hey, I think you need x, y, and z and would benefit from this many minutes of treatment this many times a week". A PT should decide how many PT minutes are appropriate, an OT should decide how many OT minutes are appropriate, and an ST should decided for ST.  When you are a green therapist coming out of school, this is what you expect to happen. Ethical treatment based on patient need, imagine that. In an SNF it's simply not the case. Therapists are reprimanded for not getting their "minutes", even if the patient is sick, or out of the building, or just refuses and doesn't want therapy.

And then there's the worst word in rehab, the dreaded "P" word... Productivity. SNF therapists and therapy assistants are paid hourly, and are expected to see patients to provide billable therapy from about 80% to 90% of their day depending on what kind of therapist you are and the company you work for. I've even heard some places that require 100% billable time (HOW??).

Do you only have 3 patients on your schedule? You are sent home early. Do you have 20 patients on your schedule? You may be looking at a 12-15 hour day. You probably won't know what your schedule looks like until the day before, or maybe the morning of, so good luck planning anything with your family or friends for after work. This is no 9-5 job.  

Do you have to spend an hour in a meeting? Your boss will tell you that you have to be there, but then reprimand you later for having low billable productivity that day. Maybe you'll be more talented than me and learn astral projection so your mind can be in the meeting while your body is performing therapy. Neato, write that skill down on a resume.

Do you think you might need about 5 minutes to write up notes on each of your 12 patients? Well that's about an hour out of your day right there where you're not being "productive". Even though you are doing the job they pay you to do...it doesn't actually count and it will stop you from getting a raise.

Do you have to spend 5 minutes helping a resident, who isn't on your schedule, transfer safely to the toilet because there's not enough floor staff to answer call bells? Companies hate that. tsk tsk. Is your patient vomiting and you're spend 10 minutes holding a bucket for them and stroking their hair? That's cutting into productive time! Just leave them! 

Do you need to use the bathroom? Maybe you should think about wearing an adult diaper. It would save 5 minutes of your time, and after all, if it's good enough for your patients it's good enough for you :)  

You know those federally mandated two 15 minute breaks per 8 hours worked that every full time employee in the US is supposed to get? You don't get them if you work in rehab. Because that would mean you're not spending time seeing patients! Shame on you.

Of course I'm being hyperbolic with most of my statements above. But when half the staff in the department is reduced to tears from stress and the other half quits, something is really wrong.

Even though I really spent about 95-100% of my time working (sure...maybe 5% on breaks and socializing and trying to be part of a team environment), according to my productivity tracker at the end of the day I hovered around 60-75%. Sometimes worse, sometimes better. It is stressful to be constantly talked to about how slow you are from your boss, while you are honestly working as fast as you can. It really made me feel like a failure.  

Let's talk about benefits.

Vacation days? What are they? SNF companies will say that because they want you to be well rested, they will not let you cash out your vacation time. They want you to take your well deserved vacation so they're not going to tempt you to overwork yourself by providing money for unused days, and they're not going to let you carry over any days from last year. How nice of them! The only problem is that you can only take vacation day if you find another therapist who can cover for you. Sometimes you might work in a rural area with no other speech therapists. When I worked full time in an SNF rehab department, I had one day off in an entire year.

And yet they would cut my hours during the week because of a low census, and ask me to come in on weekends instead when the new admissions come in. There were some months that I worked 21 days in a row but still only was just barely completing 30 hour weeks. And if there happened to be a week where i had worked 38 hours by Thursday at 5, they still wanted me to come in for 2 hours Friday but didn't approve overtime beyond that. They didn't give a rip about wasting my time. I should have learned to put my foot down, but I was new and didn't want to make waves. 

Neither of my companies provided matching for my 401K. Both SNF companies I worked full time for had frozen all pay raises for years. The only way to get a raise was to quit and negotiate for a higher salary with a new company. Wow, what a way to inspire company loyalty. Often a new graduate therapist will come into the building on day one making more than a therapist who has worked there for 10 years. Also, when I had gave 30 day notice I met a few of the SLPs interviewing to fill my position. I know that at least one very qualified, super experienced person was not hired because she asked for a high salary due to her high worth as a therapist. It really breeds resentment and fear to know that you are not valued in a current company even as you work hard to improve, and you might not be hired somewhere else because they would rather hire someone green they can control more easily and pay less.  

It's just an insane system. With the crazy census fluctuations, they don't want to hire more full time employees, which means the full timers are worked to the bone with crazy unpredictable schedules with no time to prepare quality therapy and complete all paperwork with sometimes only 10 minutes of actual scheduled break time during the entire day. And by "break time" i mean time when you are walking to get the next patient.

Rehab SNF is tough a work environment to handle and I understand why therapists feel the pressure to be unethical, bill for terrible treatments, double up on patients, etc. Because these companies are asking too much. The system is breaking down. They say they are providing patient first care, but they are not.

Advice I have for a clinical fellow, or a green employee entering the rehab world, is to remember the companies really don't give a shit about you as an employee. I hope you choose to continue to provide the most ethical care you can, providing quality therapy to those who need it. Be a good, thorough worker but do not worry about busting your butt to meet an impossible productivity standard. Don't feel like a failure because you don't measure up to corporate standard. You are worth more than they are paying you. Ask for things you want. And document everything...CYA. 

It's really not all bad. There are really good parts about working for a SNF including independence gained, developing some professional grit, and developing close relationships with patients and families, plus awesome coworkers. Most people who find themselves working in an SNF are really good people who want to make a difference in their patients lives.  It's mostly the corporate overlords and bean counters who think we're making widgets in the widget factory instead of healing live human beings.

Overall I chalk my SNF experience up to a positive one. I really have learned so much, met some lifelong friends, and am grateful even that the negative experiences led me into travel therapy which was a vast improvement on my quality of life.

I'm going to be maintaining my speech therapy license and national board certification because I worked hard to get it, and for all my griping it is a well paid position that I can get in any state fairly easily. Overall, I really enjoyed my experience immensely more once I left the nursing facilities. In my traveling negotiations, I insisted on a 75% productivity standard for all SNF jobs, and no one was able to guarantee that for me so I never went back. Instead I had a MUCH better time in home health, acute care, and hospital inpatient rehab. None of those were without faults, and over the past almost 3 years since graduation I lost my spark for the field which is why I'm now moving on. I may return in the future! I might even try transitioning to pediatrics...wow that's a sentence I never thought I would say!