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The Role of OT in Skilled Nursing Facilities

Have you ever wondered about the role of OT in skilled nursing facilities, or SNFs? If so, this article is for you!

We’ll dive into what a SNF is, what an occupational therapist SNF position entails, and what types of patients OTs typically see at SNFs. We will also include some tips for OTs and OT students looking to work in the SNF setting. 

Want to learn more about OT in SNFs?
Grab a copy of “12 Case Studies” by Timisha Tross.

What is a Skilled Nursing Facility (SNF)?

A skilled nursing facility is a facility that offers skilled medical expertise and services with 24 hour nursing care and regular rehab services to help individuals affected by illness or injury regain their independence and possibly return home after.

Patients admitted to the hospital that demonstrate decreased functional independence and who are unsafe to go home are sent to skilled nursing facilities for subacute rehab, where they will receive occupational therapy, physical therapy, and speech therapy if needed.

SNFs are sometimes still referred to incorrectly as “nursing homes,” but this terminology is technically incorrect as the patient care at SNFs does require skilled care from nurses, physicians, and therapists. SNFs are able to provide more significant medical care (similar to care at a hospital) that is unable to be provided at an assisted living facility or at home.

Patients who are discharged to skilled nursing facilities from the hospital for subacute rehab are likely only going to be there temporarily for rehab. If they do need long term placement with daily assistance, they will likely be moved to an assisted living facility after rehab. However, this is only if they will be unable to be cared for at home by family or care for themselves independently. 

What Do OTs Do in Skilled Nursing Facilities?

When patients are transferred to a SNF for subacute rehab, they will be evaluated by an occupational therapist and will receive treatments/interventions to increase their safety and independence with their desired activities of daily living (ADLs) and functional mobility.

Typical SNF occupational therapy treatments include occupation-based interventions with an emphasis on ADL retraining, which can address bathing, dressing, grooming, toileting, and self-feeding. These treatments also typically have an additional focus on transfer training and functional mobility needed during these self-care tasks.

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Therapists also address Instrumental ADL (IADL) retraining which can include home management tasks, money management, medication management, and community re-entry tasks. OTs can address any activity a patient wants to return to doing in subacute rehab to help the patient regain their independence.

To help patients become stronger to complete their self-care tasks, OTs may also incorporate preparatory activities which help prepare their patients for greater independence in their ADLs. Some examples of preparatory activities include targeted therapeutic exercise, modalities, activity tolerance retraining, balance retraining, and cognitive interventions. 

OT practitioners will also provide patient and caregiver education, equipment recommendations, and group treatments if appropriate. All of these interventions can be carried by an occupational therapist or occupational therapy assistant as directed per the patient’s individual plan of care.

Patients receiving occupational therapy services in the subacute rehab setting will also be working with physical therapists to address the patient’s decreased strength and mobility. The patient may also be receiving speech therapy services to address swallowing or cognitive impairments.

What Types of Patients go to SNFs?

Occupational therapists working in SNFs will work with patients with any diagnosis that impacts their independence. If a patient has had a decline in function and is unsafe to go home from the hospital, they can be admitted to a SNF for subacute rehab following their acute hospital stay.

Prior to being admitted to a SNF, they are evaluated in the hospital by occupational and physical therapists who make these recommendations. The diagnosis criteria to go to a SNF for subacute rehab is not as strict as an acute rehab facility, which entails more intense therapy. We’ll go into the differences of the rehabs in the next section.

The most common diagnoses seen at SNFs are strokes, brain injuries, orthopedic injuries (typically after a fall), UTIs, post-joint replacement surgery, cancer, pneumonia, or other acute cardio-pulmonary dysfunction. Patients can be admitted with any other illness/injury that resulted in their hospital admission that has caused significantly decreased strength and independence.

Many patients admitted to SNFs are older adults that may not be able to tolerate a more intensive, shorter stay at an acute rehab facility.

What’s the Main Difference Between Subacute Rehab and Acute Rehab?

Subacute rehab is the above-mentioned rehab completed at a skilled nursing facility. Acute rehab is more intense rehab typically done at a hospital acute rehab unit or freestanding acute rehab facility.

Patients in subacute rehab will have around an hour to an hour and half of therapy per day, versus three hours a day in acute rehab. In acute rehab, the average length of stay is shorter, at around 10-12 days. In subacute rehab, patients may stay several weeks or more if needed.

Acute rehab patients are typically very active and fully independent before their hospitalization and can tolerate the intensity of three hours of therapy per day. Subacute rehab patients may also have been independent prior to their hospitalization but are at a lower level and may not be able to tolerate three hours of therapy per day.

For more information on all of the possible outcomes after the hospital, read about the full continuum of care in the article titled Navigating Through The Occupational Therapy Continuum Of Care

How Many OTs Work in SNFs?

According to AOTA’s Workforce Survey from 2015, approximately 19.2% of OTs worked in SNFs/long term care and 55.9% of OTAs worked SNFs/LTC.

These numbers are approximate and may differ today following subacute rehab therapist layoffs after Medicare reimbursement rate cuts in October of 2019. We will update these numbers when AOTA releases their updated workplace survey.

Despite last year’s reimbursement rate cuts, therapy in skilled nursing facilities is still crucial for the hospitalized patients that need additional therapy prior to going home. 

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What to Look for in a SNF OT/COTA Position

Despite the above mentioned therapy cuts, SNFs are still hiring occupational therapists and COTAs since they’re an essential part of the patient’s rehab process. 

The biggest thing to keep in mind as a therapist looking into working at a SNF is the SNF position’s daily productivity requirements. For-profit SNFs are notorious for having some of the highest productivity requirements of all therapy settings.

A 2019 study found that clinicians in SNF settings were four times more likely to report unethical behavior than all other settings, with SNF clinicians also reporting the greatest prevalence of productivity standards. Read about the study here: Are Productivity Goals in Rehabilitation Practice Associated With Unethical Behaviors? (Tammany, O’Connell, Allen, and Brismee).

You’ll absolutely want to inquire about the productivity expectations while interviewing. If a facility has productivity requirements of greater than 85% for OTs and 90% for COTAs, my personal advice is to move on to a position with more attainable requirements.

That being said, don’t be afraid to work at a SNF. There are great SNFs out there, with realistic productivity expectations; you’ll just need to do a bit more homework on the requirements before accepting a position.

When applying for a SNF OT position, you can look at the company’s reviews on Glassdoor and Indeed to get a feel for what employees are saying. Do take the reviews with a grain of salt as the reviews can sometimes be slanted to the negative since happy employees are less likely to take the time to review.

I do recommend asking ask current therapists their thoughts on the facility before or after your SNF interview for an honest perspective.

For our full list of SNF job recommendations, be sure to check out our article 9 Things to Consider Before Working in a Skilled Nursing Facility.

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Want to learn more about OT in SNFs?
Grab a copy of “12 Case Studies” by Timisha Tross.

We hope this article helps give you an idea of what it looks like working as a SNF occupational therapist. If you’re an OT or COTA working in a skilled nursing facility, what other information would you share? Please let us know in the comments!

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