What is a SNF, and why would you want to work in one?

As a registered and licensed Occupational Therapist, I am here to provide the reader with the realities of the healthcare system today, with the intention of shining a bright light on the corruptions which exist and grow each day.  

So, what is a skilled nursing facility anyway? A skilled nursing facility (SNF) is essentially a place where a person goes after they have been stabilized and discharged from the hospital.  A SNF is the ‘in between’ place between an acute care hospital and being back at home.

A SNF is also a place which offers rehabilitative services which aim to increase physical strength, endurance,  independence, and safety so the person can return home, or to an alternate discharge location (i.e. assisted living, or nursing home).  The reason so many therapists flock to SNF’s is because of the massive job demand.  It is nearly impossible to be a practicing therapist these days and not be bombarded daily by recruiters trying to sell you on a “Great SNF opportunity!”  

Why then, is there such a huge need for therapists in SNF’s? Well, to be honest, the healthcare system is rigged so that there is a lucrative relationship between acute care hospitals and skilled nursing facilities.  There was a great article published last February in the Wall Street Journal which highlights how corrupt the relationship is between Medicare and Acute Care hospitals. I encourage you to read the article and familiarize yourself with its content.  In a brief summary, the healthcare system is essentially set up in such a way that it manipulates the lengths of stay for patients in order to maximize reimbursement. For example, from 2008 through 2013, an analysis of Medicare reimbursement revealed that hospitals discharged 25% of its patients during the “three days after crossing threshold” period without any evidence of improvement in their health status.  Which basically means, they discharged sick people from a facility in order to receive a sizable bonus. On average, each patient brings in about $35,000 to the hospital if they are discharged before the 3 day threshold, and only $15-20,000 if they leave after the 3 day threshold.

Now, that may not sound like a big deal, but lets look at it another way.  If hospitals are getting “bonuses” for getting patients in and out quickly, is the incentive about providing quality care, or is it about making lots of money?  If you guessed the second, you would be correct.  Which brings me back to my original question, why is there such a huge demand for therapists in SNF’s?

If a patient were sent home from the hospital before they were healthy enough, they would inevitably end right back up in the E.R within 24-48 hours. (In healthcare, these are referred to as “frequent flyers.”) Now, I’m sure you can imagine that if the same patient keeps returning to the hospital, with the same chief complaints, this is going to cause Quality Assurance to take a look at what the nurses and doctors are doing wrong.  I can assure you, no hospital ever wants an investigation.  So, Medicare came up with a solution.  Hospitals keep the patients for three days to stabilize them, and then send them off to a SNF to be reconditioned, or in other words, achieve the level of health we all once enjoyed from our hospitals.  Now, the SNF differs from an acute care hospital in the sense that the longer a person stays, the greater the amount of reimbursement the facility receives.  In other words, there is a very shady business ploy at work here. These patients are being admitted to SNF’s in very ill and deconditioned states. Financially, this is great news for the SNF. The sicker they are, the more services they will require: nursing, physical therapy, occupational therapy, speech therapy, social services, and psych. My goodness, that’s a lot of money!  So, the hospitals flood the SNF’s with patients, and the facilities are so overrun with patients, that they practically put out the bat signal to any therapist within a hundred mile radius.    

So why would you want to work at a SNF? In truth, you really wouldn’t.  Imagine working in a facility which follows the mantra: show me the money!!!

While working in a SNF, there might be some questionable ethical dilemmas placed on you from time to time, or even, all of the time. If you work in a SNF, you can expect medically fragile patients, with low rehab potential, ultra high RUG levels (Resource Utilization Group which determines the amount of money per day that Medicare will pay for a patient’s stay at the sub-acute facility.) and unrealistic productivity standards.  Typically, the standard is 90%, which affords you approximately 7-11 minutes a day to move from patient rooms to the rehab gym, speak to family members, speak to nurses, speak to doctors, or even other members of your team, and don’t even try to imagine a bathroom break; there’s little time in your day for those non-productive behaviors. So leave the coffee and ethnic foods at home where they belong because if you don’t meet your productivity standard, you risk not being paid for your day or worse, being terminated.  

Facilities have little interest in knowing that your patient walked for the first time, or moved their arm after surviving a stroke, if it means you were only 87% productive.   Most of the victories a therapist experiences each day remain a private and personal celebration between you, and perhaps the patient and family.  

There is a difficult balance to be kept between the therapeutic gains of a patient, and the insatiable craving for profits by the facility.  In order to keep receiving money for a patient there must be some indication that the patient is improving. If no improvement is observed, Medicare will sever reimbursement immediately.  Obviously, this is not what the facility wants, because there goal is to maximize reimbursement.  On the other hand, if the patient improves too quickly and is discharged before originally anticipated, the facility makes even less money.   Therefore, the message we therapists receive from our facilities is, “bring them along slowly, and let’s milk this for all its worth.”  A therapist working in a SNF is not even expected to be very good at their job, just good ‘enough’ to meet the minimum requirements to keep the money flowing in.  
So I ask this question again, “Why would you want to work in a SNF?”