7 Things to Know When Staffing Your Rehab Department
As a company working primarily with SNFs who are either in-house or interested in going in-house, we often work with our clients on understanding how to staff their therapy department. In many cases, the professionals who are hiring for SNFs and CCRCs are used to staffing nurses, CNAs, custodial staff, dining services staff, etc. And many of those staffing models are based on Patients Per Day (PPD). This is primarily because it is a fairly standard equation to determine how many staff you need based on X number of patients/residents in the facility. By and large this works for those departments mentioned above. However a PPD staffing model rarely works for the therapy department. Read on to learn why and what you should keep in mind when staffing your therapy department…
Therapy staffing models are usually based on productivity. Therapists are accustomed to working on a productivity basis and they understand that the hours “available” to them are often based on billable time. Productivity is measured differently in different healthcare settings... In outpatient settings, it may be based on the number of patients treated in a day. In home health, it may be based on the number of visits per week plus the hours of administrative time (meetings) required. In SNF and CCRC settings, it is usually based on a calculation of billable (treatment) hours and the therapist’s overall time on-site. For example, a therapist who treats 6 hours per day and works 8 hours has a 75% productivity for that day. Knowing that this is how therapists' hours are managed and allotted can leave HR professionals scratching their heads as they try to figure out whether therapists will fit into their current staffing models.
We have discovered that most SNFs and CCRCs who have historically outsourced therapy usually have their job classifications structured in a somewhat rigid format. For example, a full-time employee at their facility works 40 hours per week. Not 38 or 35, but 40 hours. While that might work well in a PPD staffing model where the number of staff who are working each day is determined by the scheduler or Director of Nursing (DON), therapy staffing needs to be much more flexible due to the nature of the service type we are providing. The same goes with part-time or PRN staff in most SNFs and CCRCs - by default the classifications are usually very structured. However, in most therapy companies, job classifications instead are written with a range of hours to allow for productivity to drive the hours worked and not a PPD staffing model. For example, many therapy companies have full-time set as 30-40 hours, part-time as 15-30 hours, and PRN simply “as needed”. In both the full-time and part-time classifications, those therapists are usually scheduled regularly in the department by the therapy manager, but those scheduled hours are based on the current caseload available to be seen, and the actual hours worked by the therapist is even further adjusted based on the actual number of patients seen that day. While the therapy manager may have scheduled the therapist to work for 6 hours today, three out of eight of the patients on that therapist’s schedule were unavailable. This means that the therapist likely has 2-3 hours less billable time than expected for that day and, therefore, should end up leaving well before they approach the 6 hours they were scheduled for. Sounds complicated? Well, it can be, but such is the nature of staffing a therapy department. AND the good news is… most therapists understand this staffing model and know how to work within it.
Due to the ability of therapists to generate revenue for the facility (in either direct dollars via insurance reimbursement for both Part B and commercial insurance patients or in the Medicaid daily rate for those in case-mix states), rehab professionals are often seen as a commodity. This means that your therapy department can generate additional revenue for your facility other than just seeing the short-term rehab patients. You should look at your therapy department as a commodity or revenue center instead of a cost center. As such, rates of pay are usually determined by education and experience, job classification (full-time, part-time, PRN), and most importantly by supply and demand.
We often work with clients who use purchased salary surveys (from which they generate salary scales) to determine pay rates for therapy. Unfortunately, the pay scales are usually a few years out of date (due to survey, processing, and printing timelines) by the time they land in the HR office of a SNF or CCRC. The therapy staffing world is a fast-moving place where market forces can change fairly regularly. As such, having someone on your team able to keep their finger on the pulse of the pay structures/rates is paramount to not overpaying (and spending too much) or underpaying (thus not allowing you to attract top talent). We have seen both scenarios. We had one client whose pay scale indicated that a SLP should make $50/hour, but that didn’t take into account the change in Medicare reimbursement that happened the year before nor did it take into account that an SLP university program had started in the immediate area. In this case, the client stuck with their salary scale, we made an SLP extremely happy and are overpaying that position by 10-15k/year. Conversely, we have had clients who wanted to pay a PT 35/hour based on the salary scales when the going rate was more like 42.
In working with in-house facilities, we have found that PRN for other positions within SNFs and CCRCs may not mean the same thing as PRN in the therapy world. In the rehab world, a PRN employee who works in a SNF or CCRC is called upon only when needed, working hours are not promised, and the PRN employee is not obligated to work every time you call. Thus, it is important to have a stable list of good PRN therapists to call upon when the caseload expands beyond what your regular team can handle. Additionally, in the rehab world, PRN therapists are paid an hourly rate for their hours worked.
Keep in mind that many therapists who choose to work PRN are often working full-time at another facility. Therefore, keeping a streamlined on-boarding process that can be flexible is important. For example, an orientation process that can be accommodated either before or after the PRN therapist’s normal work day instead of requiring them to take a day off of work is a good rule of thumb, as well as allowing them to complete new hire paperwork from home. These are just two of the ways you can make it easier to attract needed staff. In the rehab world, a PRN rate is going to be higher than a full-time or part-time therapist, and a PRN therapist rate is typically higher than a PRN employee in your other departments. Again, this is determined by supply and demand and the fact that we are looking at this position as a commodity. It is important to understand the going rate in your area for PRN therapists. Too low and you will be the last choice when the therapist has multiple offers (and I assure you they often have multiple offers); too high and you could inadvertently be resetting the rate for the area. For as long as I have been practicing, there have been hiring shortages in therapy fields, so you will most likely need a different pay scale for rehab PRNs than you have for maintenance or security employees. Also keep in mind that while these employees may have higher rates of pay than you are using for other departments, they have no additional costs involved other than taxes. These employees will not expect any other benefits such as holiday pay or insurance. That alone saves you anywhere from 23-30% as compared to your regular staff. While there are some limited expenses in bringing a new PRN onboard, make sure you have enough PRN therapy positions filled so that your team has coverage for their planned days off and also for unexpected sick days. The loss of revenue and care for your residents is a much higher cost than the small amount it will cost you to bring a PRN person on-board.
Rehab professionals are typically not hired as salaried employees. With the exception of the Department Head or Director of Rehab, your full-time and part-time employees should be paid on an hourly basis, just like the PRNs. Additionally, there are productivity expectations that you should set for each position. As mentioned earlier, while your productivity for nurses is managed by staffing levels based on census, productivity in the therapy department is managed by a calculation of the therapist’s billable and non-billable hours in the building. Therefore, by paying therapists hourly, hours can be adjusted alongside normal fluctuations in caseload and they can leave work early when their services are not needed. It is important to know that this is standard industry practice for therapists in long-term care. The exact productivity expectation varies from one company and/or building to another. Typically the expectation is higher for assistants who have little responsibility for documentation other than daily notes, than it is for evaluating therapists who have more documentation requirements. Taking into consideration the other non-billable responsibilities you may assign to therapists should also come into account as you set your facility’s productivity expectations.
Unless you have a therapist who understands and follows the tax and liability insurance implications of being self-employed, we recommend hiring therapists as W2 employees whether or not they are being hired for full-time, part-time, or PRN status. Most therapists are not out there running their own companies (working as 1099 contractors) and so they do not fully understand all that is involved in doing so. So unless they are asking to be a 1099 contractor, it is usually best for everyone involved that you bring them on as a W2 employee.
Most therapists just want to take care of people. That’s why we all got into the healthcare field in the first place! I learned early on in rehab management that talking dollars and cents as it relates to patient care can be the quickest way to “turn off” a therapist who really wants to just take care of people. Therapists as a rule, and as required by regulation, are highly educated and usually intelligent people. However when outlining expectations for new employees (or talking with current employees), it is important to make sure expectations are explained in a way that the therapist can relate to, so that everyone can be on the same page. This is one reason why having a therapist oversee and manage other therapists is best practice. The Administrator, CEO, CFO, or COO can talk about rehab revenue and productivity, but therapists want to know that what they are doing matters in the lives they touch every day. So taking the time to explain the marriage of quality of care with fiscal responsibility will help therapists understand how the choices they make ultimately affect the care they can provide to residents. Mark once had a mentor who said, “With no margin, there can be no mission” - and as we all know, mission is the driving force in an industry committed to helping improve residents’ lives. Educating therapists to fully understand how the mission is funded often makes them more valuable team members who work with you toward shared goals.
Understanding how to properly staff rehab professionals is a key component of a healthy therapy program. However, the nuances of therapy staffing sometimes cause administrators and owners of SNFs and CCRCs to hire a contract therapy provider. You may have felt like you had to choose between the headaches of an in-house therapy program (like staffing) or the loss of profits when contracting out. But at Seagrove Rehab Partners, we offer an innovative third approach to therapy that gives you the most tempting benefits of a contracted program - including support and assistance filling your open positions - while keeping your profits in-house. For members of our monthly In-House Therapy Alliance®, we create a custom staffing model and keep an eye on your therapy staffing levels and pay rates, and that’s just one part of our comprehensive monthly oversight. Do you ever wish you could get a bird’s-eye view on how your contracted therapy program is actually performing or how your in-house program is running without professional oversight? Call me at 850-499-4345 to request a complimentary assessment, so you can know precisely how well it’s benefiting your residents, team, and bottom dollar.
Written by: Elizabeth Johnson, PT, CDP, RAC-CT
