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

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