Patient Functional Outcomes in Skilled Nursing Facilities: The Mediating Role of Declining Therapy.

OBJECTIVE

To estimate changes in functional outcomes in Medicare fee-for-service skilled nursing facility (SNF) patients after declines in therapy minutes that occurred after Patient-Driven Payment Model (PDPM) implementation and during the COVID-19 pandemic. We also tested the hypothesis that declines in therapy minutes mediated changes in patient functional outcomes.

DESIGN

Retrospective cohort study using mediation analysis. Exposures were PDPM implementation (October 2019) and COVID-19 pandemic onset (March 2020). The mediator was average minutes of therapy per day (MTD) including all physical, occupational, and speech therapy minutes during the SNF stay.

SETTING

All US SNFs.

PARTICIPANTS

Patients (N=3,534,928) at post-acute SNF stays from January 2018 through September 2021.

INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES: Functional outcomes based on changes in activities of daily living (ADL) scores between SNF admission and discharge, measured by a validated 28-point scale: (1) ADL decline and (2) high ADL improvement (≥4 points improvement). Mediation analysis quantified effects of declining MTD on functional outcomes, adjusting for patient, facility, and community-level confounders.

RESULTS

Average MTD declined from 122.2 pre-PDPM to 96.5 post-PDPM and further to 87.7 during COVID-19. After PDPM implementation, the adjusted probability of ADL decline increased by 1.7 percentage points (pp) (95% CI: 1.6-1.7); during COVID-19, ADL decline increased by 3.7 pp (95% CI: 3.6-3.7). Declining MTD mediated 47.9% of the increase in ADL decline post-PDPM and 26.5% during COVID-19. The adjusted probability of high ADL improvement increased by 1.3 pp (95% CI: 1.1-1.3) post-PDPM and 1.0 pp (95% CI: 0.8-1.0) during COVID-19. Declining MTD negatively mediated this increase in high ADL improvement by -2.9 pp post-PDPM (95% CI: -2.9 to -2.9) and by -3.5 pp during COVID-19 (95% CI: -3.6 to -3.5).

CONCLUSIONS

Declines in SNF therapy after PDPM implementation and during COVID-19 mediated substantial worsening in patient functional outcomes. Ensuring adequate therapy provision may improve functional recovery in SNF patients.