Why Everything Is Changing in Therapy — and You Should Too

Why Everything Is Changing in Therapy — and You Should Too

Gravity Healthcare Hacks | Episode 64

The therapy landscape is shifting—again—and many senior living and skilled nursing operators are still relying on rehab strategies that no longer work.

In this episode of Gravity Healthcare Hacks, Melissa Brown is joined by Carly Chronister, Lead Consultant of Therapy Services at Gravity, to break down what’s really changing in therapy and why now is the time to reassess your approach.

They explore how the transition to PDPM fundamentally altered the role of therapy, why contract therapy models are struggling to deliver meaningful value in today’s reimbursement environment, and how PDPM Medicaid has further reshaped incentives—often in ways operators didn’t anticipate.

This conversation goes beyond theory and gets into what operators should actually be watching inside their buildings, including therapy minutes, outcomes, Section GG accuracy, nursing involvement, and where risk is quietly building under the surface.

If you’re questioning whether your current rehab strategy is still serving your residents—or your organization—this episode will help you understand what to look for, what’s changed, and what to rethink moving forward.

🎧 Subscribe to Gravity Healthcare Hacks for practical insights on operations, reimbursement, and strategy in senior living and post-acute care.

Transcript

Why Everything Is Changing in Therapy — and You Should Too

Gravity Healthcare Hacks – Episode 64

Melissa:
Hello everyone, and welcome to today’s podcast, Why Everything Is Changing in Therapy — and You Should Too. I’m really excited to have Carly Chronister, our Lead Consultant of Therapy Services, on for this robust discussion today. Welcome, Carly.

Carly:
Hi, Melissa. Thanks for having me.

Melissa:
It’s wonderful to have you here. Let’s start by level-setting for our audience. Can you share what you do at Gravity as our Lead Consultant of Therapy Services and how you help clients work through challenges related to rehab?

Carly:
Sure. I’ve been with Gravity now for about ten years in some capacity, but more recently my focus has been in the Lead Consultant role. A large part of what I do is managing in-house therapy programs—making sure therapists and teams are up to date on regulatory requirements, best practices, training, and staff education. I act as a clinical arm, but also from a compliance perspective.

Ultimately, it’s about managing the entire therapy department and ensuring administrators are getting what they need from their therapy teams. In a consulting role, we also take on a lot of unique projects, which is exciting, but my primary focus is managing and optimizing therapy programs.

Melissa:
That’s a great place to start. So why is now the time that things are changing? Why should operators be rethinking their rehab strategy in today’s landscape?

Carly:
When PDPM replaced RUGs, we shifted away from volume-based billing—chasing minutes—to delivering services based on resident needs and clinical complexity. Under RUGs, it was easy for therapy to demonstrate value through reimbursement tied directly to minutes.

Under PDPM, that changed. Therapy teams now need strong clinical leadership to demonstrate their value, and that’s not always what contract therapy companies were built to provide. PDPM created a real opportunity for operators to evaluate whether their therapy partners are delivering what’s actually needed in this new model.

Melissa:
That’s such an important point. PDPM was implemented over five years ago, but one of the unintended consequences we didn’t fully predict in 2019 was the devastation it would cause in skilled care.

Having worked with many contract therapy companies leading up to PDPM, I saw negotiated rates get pushed so low that there simply isn’t enough margin left for them to deliver meaningful rehab services. What we’re seeing now—and this may be happening in your building—is skilled patients receiving as little as 15 minutes of therapy per day, while long-term care residents are getting 55 to 60 minutes. Clinically, that makes no sense.

We’ve been called into buildings for rehab audits where this is exactly the case. I’m not saying therapy minutes didn’t need to come down under PDPM—there was some artificial inflation under the old system—but what we’re seeing now is an overcorrection. Contract therapy companies are struggling to break even, so they’ve shifted focus to Part B, often at the expense of skilled patients.

What are you seeing out there, Carly?

Carly:
I agree completely. From a financial standpoint, under PDPM the facility receives the PT, OT, and speech daily rate whether therapy services are delivered or not. Meanwhile, the contract therapy company absorbs 100% of the cost of staffing those therapists.

So what’s incentivized? If they’re paid a percentage of your revenue and they absorb the staffing cost, the only way to increase their margins is to reduce therapy minutes and push productivity. That’s really it. Since reimbursement is no longer tied to volume, therapy minutes naturally come down under contract models.

Melissa:
Right. And we know from the FY 2023 proposed rule for SNFs that the industry average target is about 30 to 40 minutes per day. That’s actually a very reasonable amount of therapy and is correlated with strong outcomes.

In our experience, those minutes often exceed the necessary thresholds for Section GG mobility and self-care when teams are properly trained. But if your building is averaging below 30 minutes per day, that’s a red flag. You should be concerned and start evaluating whether a change is needed.

And importantly—don’t expect your contract therapy provider to simply increase minutes because you ask. We’ve seen them say yes and then fail to deliver. Carly, what do you recommend operators think about when evaluating this?

Carly:
I like to look at therapy metrics as a complete picture—outcomes, length of stay, and minutes delivered. If outcomes are strong and minutes are around the national average, that makes sense.

But if outcomes are poor and therapy minutes are below average, that paints a very clear picture: you’re not delivering the right level of care. That has downstream effects on everything—outcomes, audit risk, denials, and more.

I also look for imbalances. Are minutes high but length of stay is short? Are minutes low but length of stay is long? All of that tells a story. Therapy delivery should align logically with outcomes and risk.

Melissa:
Absolutely. I love that framework. And while PDPM in 2019 was a major catalyst, it was a slow burn. What has really flipped the script recently is the shift to PDPM Medicaid.

This was the last area where contract therapy provided high financial value by driving CMI. Outside of a handful of states where speech therapy is included, contract therapy can no longer meaningfully impact reimbursement on the long-term care side. Carly, what are you seeing, and what recommendations are you making to clients?

Carly:
Under the old Medicaid CMI model, therapy providers knew exactly how to operate—screening, evaluating, and delivering minutes strategically before assessments to hit target numbers.

Under PDPM Medicaid, that’s gone. We’re back to clinical complexity driving reimbursement, and therapy no longer plays the same role in influencing CMI.

Melissa:
Exactly. Even screening strategies have changed. What we recommend now is having speech therapy involved about a week ahead of the ARD so they can document swallowing or speech-related comorbidities within the seven-day lookback period.

If there are no other indicators, PT and OT are often better engaged after the ARD, when a Section GG decline may trigger a referral. If therapy intervenes too early, they may resolve that decline before it’s captured—reducing the per diem.

In most states—around 30—PDPM Medicaid is nursing-only or nursing plus NTA. Therapy isn’t included. That makes accurate Section GG coding even more critical. Carly, what other strategies are you recommending around PDPM Medicaid and therapy?

Carly:
One of the best things a community can do is invest in nursing staff education around Section GG. Accurate coding is critical, especially when therapy isn’t involved early.

Historically, therapists often supported Section GG data collection, even though that’s not how it’s written from a regulatory standpoint. Now, nursing teams need to feel confident collecting accurate data themselves.

Melissa:
Absolutely. MDS coordinators also need to be savvy. If they’re not, audits, training, and mentorship can make a huge difference.

Too often, data auto-populates from nursing documentation into the MDS, and it becomes a “click it and move on” process. That doesn’t serve the MDS—or the resident—well.

If there’s a significant ADL decline, therapy should be notified. If the numbers don’t make sense compared to the prior ARD, there should be follow-up. It could be a real decline, a documentation error, or simply a misunderstanding—especially with new staff.

You and I have been working with Section GG for five or six years, and there are still nuances that trip us up. So it’s completely understandable that frontline staff struggle without proper support.

Carly:
I agree. Nursing plays a much larger role in reimbursement now than it ever did under RUGs.

Therapists genuinely want to do what’s right for patients. They want residents to improve, not decline. But we also have to be strategic about how care is delivered within the reimbursement model. That balance is critical under PDPM.

Melissa:
Exactly. Therapy has changed the game, and it’s one of the many reasons we’re saying therapy is changing right now—and you should too.

Next month, we’ll have a follow-up episode where we dive deeper into additional changes and how operators should respond.

Thank you, Carly, for joining us and sharing such valuable insights. And thank you to everyone listening. If you enjoyed this episode, don’t forget to subscribe. Remember—it’s not just what you know, but how you apply it that makes all the difference. We’ll see you next time.