# The role of declining therapy volumes in skilled nursing facility outcomes: a mediation analysis

## TL;DR

This study examines how reduced therapy in nursing facilities after a policy change and the pandemic affected patient outcomes like discharges and readmissions.

## Contribution

The study identifies declining therapy volumes as a key mediator of worsened patient outcomes in skilled nursing facilities.

## Key findings

- Average therapy minutes per day dropped from 122.2 to 87.7 after policy changes and the pandemic.
- Reduced therapy was linked to lower successful discharges and higher readmissions.
- Findings were consistent for patients with dementia and moderate functional impairment.

## Abstract

Significant declines in therapy provision in skilled nursing facilities (SNFs) followed the 2019 implementation of Medicare's Patient-Driven Payment Model (PDPM) and the onset of the COVID-19 pandemic, raising concerns about effects on patient outcomes.

Using Medicare fee-for-service claims and SNF assessment data from January 2018 through September 2021, we analyzed 3.5 million post-hospital SNF stays to assess whether changes in therapy volumes mediated changes in successful community discharge and 30-day hospital readmissions.

Average total physical, occupational, and speech therapy minutes per day declined from 122.2 before PDPM to 96.5 immediately after implementation and to 87.7 during the pandemic. Adjusted probabilities of successful community discharge rose modestly after PDPM but fell during COVID-19, while readmissions declined initially and then increased. Mediation analyses showed that reductions in therapy volumes were strongly associated with the declines in community discharge and increases in readmissions. These findings persisted for patients with dementia and moderate levels of functional impairment at admission; declining therapy volumes were associated with the observed worsening of discharge outcomes after PDPM implementation and during the pandemic.

Results highlight therapy provision as a key modifiable policy target for improving post-acute outcomes and reducing rehospitalizations among older adults in SNFs.