Therapy Assistants Staffing and Patient Outcomes in Skilled Nursing Facilities

By Rachel Prusynski

Every year, over 1 million Medicare beneficiaries receive nursing and rehabilitation services in Skilled Nursing Facilities (SNFs) to help with recovery after a hospital stay. The goal of physical and occupational therapy in SNFs is to help patients regain their functional mobility, discharge back to the community, and avoid being readmitted to the hospital. In SNFs, patients can receive therapy provided by occupational and physical therapists who perform evaluations, treatments, and discharge assessments, or occupational and physical therapy assistants, who are only licensed to provide treatments under therapist supervision.

Therapy assistants receive less formal education than therapists, but SNFs are incentivized to employ more assistants because assistants receive lower salaries than therapists, while therapy provided by assistants is reimbursed to the facility at the same rate. This study examined whether there were differences in outcomes for patients in facilities who employed more assistants compared to therapists.

Using data from over 13,000 SNFs in the United States in 2017, we looked at how the proportion of therapy assistants on staff was related to three patient outcomes: the percentage of patients who: 1) improved in functional mobility, 2) successfully discharged to the community, and 3) avoided hospital readmissions after SNF discharge. In our analysis, we controlled for other facility characteristics such as the overall amount of therapy patients received, how long they stayed in the SNF, ownership and geographic variables, nurse staffing, and whether therapy departments employed contract staff.

We found that, regardless of the mix of assistants and therapists on staff, rates of patient functional improvement were similar across facilities. Compared to facilities that had no assistants or high levels (>75%) of assistants on staff, community discharge outcomes were best in SNFs that employed a fairly even mix of therapists and assistants: between 25-75% of assistants compared to therapists. Readmission outcomes were slightly worse in SNFs that employed high levels (>75%) of occupational therapy assistants compared to occupational therapists. At the same time, the overall amount of physical therapy patients received during their SNF stay was positively related to all outcomes.

We concluded that a more even mix of therapists and assistants was associated with the best outcomes for SNFs. This may be because therapists and assistants have complimentary skills and focus areas. Therapists can focus on evaluation, discharge coordination, and treatment progression, while assistants can provide the repetition needed to help patients learn new skills in treatment sessions. Both areas may be important for patients to successfully discharge to the community from SNFs.

This study is especially interesting because there have been large declines in therapy staffing in SNFs after new Medicare payment policy in 2019 and during the COVID-19 pandemic. Therapy assistants have experienced the brunt of staffing cuts. But our study suggests it may be smart for SNFs to employ more assistants who can provide therapy to patients at lower cost to the facilities. An even mix of therapists and assistants may help SNFs achieve the dual goals of better outcomes at lower overall staffing costs.

Article details

Therapy Assistant Staffing and Patient Quality Outcomes in Skilled Nursing Facilities
Rachel A. Prusynski, Bianca K. Frogner, Susan M. Skillman, Arati Dahal & Tracy M. Mroz
First published online July 22, 2021
DOI: 10.1177/07334648211033417
Journal of Applied Gerontology

About the Author

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Rachel Prusynski is an Assistant Professor in the Division of Physical Therapy in the Department of Rehabilitation Medicine at the University of Washington. She received her PhD in Rehabilitation Science at the University of Washington and her Doctorate of Physical Therapy at the University of Puget Sound. Her health services research agenda focuses on the intersections between health and reimbursement policy, therapy practice, and patient outcomes in post-acute care, specifically Skilled Nursing Facilities. She is a board-certified clinical specialist in Neurologic Physical Therapy with a decade of clinical experience across the continuum from ICU to community-based care. Her experience in Haiti and in the U.S. working with low-income older adults guides her research interests in quality of care and equity for historically marginalized communities.