Strategic Application of Group and Concurrent Therapy in Long-Term Care

Editor's note: This text-based course is a transcript of the webinar, Strategic Application of Group and Concurrent Therapy in Long-Term Care, presented by Kevin Cezat, PT, DPT, GCS, RAC-CT.

*Please also use the handout with this text course to supplement the material.

Learning Outcomes

• After this course, participants will be able to state CMS guidelines on what qualifies as group and concurrent therapy.
• After this course, participants will be able to list current restrictions and requirements for providing group and concurrent therapy within long-term care across multiple payors.
• After this course, participants will be able to list at least three strategies to overcome common barriers to providing group and concurrent therapy.

Introduction

Thank you everyone for joining. Before diving into the content, I’d like to share more about my background. I think it’s important to provide context about my experiences and perspective because, as a presenter, I bring certain biases shaped by my career. These might differ from your experiences or views, so I want to give you a sense of where I’m coming from.

I’ve been practicing for about 15 years. I graduated from UCF, a university in Central Florida, and started my career in long-term care. I was fortunate to work primarily in a Continuing Care Retirement Community (CCRC) in Winter Park, Florida. It was a beautiful facility, primarily serving Medicare payors, with a mix of primary and secondary payors, which was a valuable learning environment. The setting included skilled nursing, assisted living, independent living, and home health, all within the long-term care and geriatric framework.

While I’ve worked in other facilities, the bulk of my early career was spent at that CCRC. I started as a staff clinician and later became a rehab director, a role I held for many years. I work in clinical quality education, overseeing numerous facilities across several states. I’m licensed in Florida, Arizona, and Ohio, but my primary focus remains here in Florida. I also serve as vice chair for the APTA Skilled Nursing Facility Special Interest Group, which has undoubtedly shaped my positive bias toward the APTA.

In my current role, I treat patients about five hours a week, which keeps me grounded in patient care, but most of my time is spent on big-picture initiatives. This includes analyzing quality data, clinical delivery models, and strategies to improve outcomes while balancing efficiency. My experience has been heavily centered on long-term care, particularly skilled nursing facilities (SNFs), and I’ve developed a strong understanding of the Medicare reimbursement model. I’ve had limited exposure to managed care and private insurance in a clinical setting and even less with Medicaid facilities, though that has increased slightly in the past year.

My perspective includes both the boots-on-the-ground challenges clinicians face and the broader, systemic considerations of care delivery. However, like anyone, I have my blind spots. For example, when it comes to group therapy, I’ve approached it from multiple angles—staff clinician, rehab director, and now in a role where I evaluate its impact on a larger scale. I focus on understanding how group therapy can maximize clinical outcomes while remaining efficient and effective, but I remain open to learning from others’ experiences and perspectives.

Definitions and Payor Requirements

As we typically do, it’s best to start with some definitions to ensure everyone is on the same page regarding the terminology we’ll be using. These definitions are critical for understanding the concepts we’ll discuss, particularly because we focus primarily on definitions as Medicare outlines them. Keep in mind, though, that there can be variations in how private insurance defines and approaches these terms, so there may be some differences depending on the payor source.

It’s also important to note that Medicare comes with its own set of specific considerations. For example, there are instances where individual contractors, known as Medicare Administrative Contractors (or MACs), make local coverage determinations when there isn’t a national coverage determination for a particular service. You might have heard terms like "reasonable and necessary" in this context. If you’re unfamiliar with MACs, let me provide a little background.

Being as massive and complex as it is, Medicare relies on many moving parts to function effectively. MACs were created in 2003 to streamline processes and bring greater consistency and efficiency to Medicare’s operations. Before that, separate fiduciary intermediaries were helping to manage claims, but the introduction of MACs was intended to centralize and improve these processes. MACs serve as intermediaries between providers and Medicare, handling claims, appeals, and regulatory oversight.

In my area, for instance, the MAC is called First Coast. About 12 different MACs manage specific geographic regions across the country. These MACs operate under contracts awarded to private entities, typically renewed every five to ten years. While they’ve helped streamline some aspects of Medicare administration, they’re not without challenges. Recently, there’s been increasing discussion about consolidating MACs further to address some of these issues.

If you’re unfamiliar with MACs, especially if you’re newer to the regulatory and reimbursement side of Medicare, I strongly recommend familiarizing yourself with your region’s MAC. It’s essential to know how to access local coverage determinations (LCDs) because these can significantly impact the services you provide and how they’re reimbursed. Understanding your MAC’s guidelines will help ensure compliance and provide clarity on what is deemed reasonable and necessary in your practice area.

Modes of Therapy

1. Individual
2. Concurrent
3. Group
4. Co-Treatment

Individual. Let’s start with the definition of individual therapy. At its core, this refers to one-on-one treatment. The key is that the provider delivers therapy directly to one patient, maintaining full attention on that individual for the entirety of the session. Medicare’s definition explicitly states that it is inappropriate to count individual therapy minutes if treatment is provided to multiple patients simultaneously.

The phrase “full attention” can sometimes lead to confusion or even scrutiny. The interpretation, however, is specific: full attention refers to the relationship between the clinician and the patient in the context of other patients. In other words, you can still perform point-of-service documentation or other multitasking activities during an individual therapy session, as long as those activities don’t involve another patient. The intent here is to discourage dividing your focus between multiple patients, not to prohibit all forms of multitasking.

This opens up an interesting conversation about multitasking and its potential impact on care. There’s an ongoing debate about how much multitasking is appropriate in clinical settings and whether it diminishes the quality of patient care. It’s a nuanced topic, and opinions vary widely depending on context, the clinician’s workflow, and the patient's needs. These are important considerations, but for the purpose of individual therapy, as Medicare defines it, the focus must remain on the uninterrupted therapeutic relationship with a single patient.

Concurrent. Concurrent therapy is defined as the individualized treatment of two residents at the same time by one therapist. In this scenario, the two individuals are not engaged in the same or similar activity, but they must remain within the line of sight of the treating therapist or assistant throughout the session. While there are specific definitions of what "in line of sight" means, the general concept is clear enough for most situations. Notably, the two residents do not need the same insurance provider for the session to be billed as concurrent therapy.

As an example from my practice, I conducted a concurrent treatment session the other day. One gentleman was performing sit-to-stand repetitions with the goal of lower body strengthening, while another gentleman was engaged in dynamic standing balance activities using parallel bars. These activities were distinct, the therapeutic intents were different, and the goals for each patient were unique. Because of this, it was clearly a concurrent therapy session, aligning with this treatment model's definition and intent.

Group. There are distinct definitions for group therapy under Medicare, depending on whether Medicare Part A or Part B. Under Medicare Part A, group therapy involves the treatment of two to six patients performing the same or similar activity. By contrast, under Medicare Part B, group therapy is defined as the treatment of two or more residents simultaneously, regardless of payor source, who may or may not be performing the same or similar activity.

There are a few nuances worth unpacking here. Under Medicare Part B, there isn’t a specified cap on the number of patients included in a group session. This is different from the explicit 2-to-6-patient range defined under Medicare Part A. Additionally, while the definition of individual therapy remains the same across Medicare Part A and Part B, concurrent therapy does not exist as a category under Medicare Part B. Everything that would otherwise fall under concurrent therapy in Part A is categorized as group therapy in Part B, regardless of whether the patients are engaged in the same or different activities.

One of the common challenges with group therapy, especially under Medicare Part A, is determining what qualifies as “same or similar” activity. There isn’t a definitive guideline, so it often comes down to clinical decision-making. Activities don’t need to be identical, and patients can have slightly different goals, but the activities should be similar enough to meet the spirit of the definition.

The good news is that accurately classifying therapy as group or individual doesn’t tend to have a negative impact. The key is simply to be as precise as possible in documentation and decision-making. This ensures compliance with Medicare definitions while aligning your clinical choices with the therapy's intended purpose.

Co-treatment. Co-treatment is another complex area with its own set of nuances. It’s defined as two clinicians from different disciplines providing distinct treatments to the same resident simultaneously. The decision to use co-treatment must be made on a case-by-case basis, and the need for it should be clearly and thoroughly documented for each instance. This approach has evolved significantly, particularly in how it’s billed and justified.

Under Medicare Part B, co-treatment requires splitting the minutes between the two therapists. However, under Medicare Part A, particularly with the introduction of the Patient-Driven Payment Model (PDPM), minutes no longer directly impact reimbursement. For Part A, each clinician can technically include all the time spent in their billing. Even so, it’s crucial to document the specific tasks each therapist addresses and ensure the minutes align between both disciplines. The co-treatment must also be coded correctly on the MDS, and the interdependence of each therapist’s goals should be explicitly documented.

It’s essential to justify why co-treatment is the best approach for the patient, emphasizing how the combined activity leads to better outcomes compared to separate, one-on-one sessions. Simply needing “an extra pair of hands” is not an acceptable rationale. In fact, co-treatment can sometimes reduce the overall therapy volume a patient receives. For instance, combining a single 40-minute co-treatment session instead of two separate 40-minute sessions means the patient has fewer touchpoints throughout the day. Therefore, it’s important to weigh whether the co-treatment provides the patient with a clear and tangible benefit.

An example often cited in this context—possibly from the RAI Manual—illustrates how co-treatment might look. Imagine a 66-year-old female, post-ischemic stroke, with left-side hemiparesis, admitted to a facility. She has hypertension, diabetes, and obesity and was previously independent, living alone in a single-level home. Her goals are improving sitting balance for self-care, achieving independence with transfers and ambulation, and using an assistive device. During a co-treatment session, the physical therapist might work on weight shifting and balance training in a seated position while the occupational therapist focuses on upper extremity dressing strategies, which require trunk stability.

These examples highlight how co-treatment can address overlapping but distinct goals, such as integrating balance and functional activities, to maximize the patient’s progress. Some of these scenarios raise the practical question of how two therapists can deliver entirely different treatments simultaneously. This challenge underscores the need for careful planning and documentation to ensure that co-treatment meets Medicare’s definition and serves the patient’s best interest.

Ultimately, co-treatment can be an effective and appropriate intervention, but it requires a clear rationale, detailed documentation, and alignment with the patient’s individualized goals. It’s not about convenience but ensuring that the combined effort results in meaningful clinical benefits.

Billing

Let’s discuss billing for the different therapy delivery modes—group, concurrent, and co-treatment—and the guidelines for each.

Group/Concurrent/Co-treat Billing Guidelines. The CPT code 97150 is used for group therapy under Medicare Part A and Part B. Under Medicare Part A, reimbursement isn’t directly tied to CPT codes, so the specific code used for group therapy doesn’t impact financial reimbursement. The focus is more on tracking and proper documentation of services.

For Medicare Part B, reimbursement depends on the code utilized, so 97150 is the code for any group session. Since concurrent therapy isn’t a billing category under Part B, anything that might align with that definition falls under the group therapy code. However, group therapy under Part B is generally not a strong reimbursement model, so it is less commonly used unless there’s a clear clinical benefit. The lack of financial motivation means group therapy is typically reserved for situations where it significantly benefits the patient.

There are no separate CPT codes for concurrent therapy under Medicare Part A. Instead, concurrent therapy is tracked and monitored through the MDS to evaluate the volume of therapy provided in this mode. While it is not billed differently, it must be properly documented as part of the data collection process. Under Medicare Part B, concurrent therapy doesn’t exist as a billing category and is instead categorized as group therapy.

For co-treatment, the billing guidelines differ notably between Medicare Part A and Part B. Both therapists can bill for the full session under Medicare Part A and the PDPM model. This reflects a significant change from earlier practices when therapists had to split the time. With PDPM, therapy minutes no longer directly influence reimbursement, allowing both clinicians to bill fully for their contributions, provided the session is well-documented.

Under Medicare Part B, co-treatment requires splitting the session time between the therapists. For instance, in a 60-minute co-treatment session involving PT and OT, the time must be divided between the two disciplines, typically with each therapist billing 30 minutes. This approach ensures compliance with billing guidelines and accurately reflects the allocation of services.

In conclusion, billing for group, concurrent, and co-treatment therapy varies significantly depending on whether it falls under Medicare Part A or Part B. Accurate documentation, clinical rationale, and adherence to guidelines are essential to ensure compliance, whether through proper coding, time splitting, or tracking therapy volumes.

Group/Concurrent Billing Considerations. For group therapy, there are specific considerations, especially for SLPs, even though much of today’s discussion is centered on PTs and OTs. One key point is the use of the 59 modifier. If you're performing group and individual therapy on the same day, you must apply the 59 modifier to indicate that the two services were completely distinct. For example, if you conduct a group session and then later in the day or immediately following, you provide an individual session, the modifier ensures proper billing and clarifies that the individual therapy wasn’t conducted within the context of the group session. Typically, EMR systems handle this automatically, but you may still need to attest that the services were distinct.

Another area of interest is student involvement in therapy sessions, which can get complicated. Under Medicare Part A, group therapy can be billed when a therapy student conducts the group, provided the supervising therapist is not simultaneously treating another resident or supervising other individuals. In other words, the supervising therapist must dedicate their attention solely to the group therapy session. Similarly, if the supervising therapist is leading the group, the therapy student cannot independently engage in another activity. Everything the student does must align with the group therapy context. 

The rules for Medicare Part B are similar. The student can provide group therapy if the supervising therapist is not engaged in another activity. Conversely, if the therapist leads the group, the student cannot independently treat another patient. Confusion often arises when students are seen running a group while the supervising therapist is simultaneously conducting individual therapy or vice versa, which is not permitted by the definitions.

Another layer of complexity is combinations involving Part A and Part B patients. It’s possible to have patients with different payor sources in the same therapy session. For example, you might have one Part A and Part B patient in a group session. This can sound confusing, but following each payor source's definitions and billing guidelines is key. Regardless of the mix, adhering to the specific rules for group, concurrent, and individual therapy ensures compliance.

When in doubt, it’s helpful to return to the definitions and ensure the documentation reflects exactly what occurred. Sticking to the established guidelines simplifies what can otherwise feel like a complicated process, whether dealing with modifiers, students, or payor combinations.

Student Group/Concurrent Billing Considerations. Let’s consider some scenarios to clarify how billing would work with one Part A and one Part B patient. These examples highlight the importance of adhering to the definitions we’ve discussed.

Scenario one: You’re treating one Part A and one Part B patient, and they’re participating in a similar or similar group activity. In this case, the Part A patient is billed as a group, and the Part B patient is billed as a group. The activity aligns with the group therapy definitions for both payor sources.

Scenario two: You’re treating one Part A and one Part B patient, but they’re engaged in different activities. For example, one works on balance exercises while the other focuses on upper body strengthening. Here, the Part A patient would be billed as concurrent because the activities are not the same or similar, and the definition of concurrent applies. The session is still billed as a group for the Part B patient since concurrent therapy does not exist under Part B. Whether the activities are the same or different, anything involving multiple patients under Part B is categorized as group therapy.

The key takeaway is that the billing should always align with the definitions, no matter how complex the combinations may seem. For Part A, you differentiate between group and concurrent based on the activity. For Part B, everything involving more than one patient is billed as a group, regardless of whether the activities are the same or different. These principles apply consistently across all combinations of patients and payor sources, so referring to the definitions ensures compliance and clarity.

Group/Concurrent Billing Considerations, cont. When considering telehealth in therapy, aligning with the definitions and billing practices for group or concurrent therapy specific to your payor or setting is crucial. Telehealth, especially in long-term care, has undergone significant evolution, largely driven by the temporary expansions during the Public Health Emergency (PHE) brought on by COVID-19. This expansion allowed for a much broader telehealth application across all therapy disciplines, with long-term care seeing considerable uptake. However, telehealth is not without its challenges, particularly in this sector.

Telehealth in long-term care varies widely by state due to differing regulations. States determine who can facilitate telehealth, the specific requirements, and how it can be implemented. From a business perspective, telehealth often poses financial challenges. Delivering therapy via telehealth in long-term care frequently requires a facilitator on-site to ensure patient safety, even in states where it’s not explicitly required. This means that facilities are paying both the remote therapist and the on-site facilitator while only receiving one reimbursement for the session. Despite this, telehealth can provide high-quality care, especially when paired with a skilled facilitator.

The telehealth flexibilities stemming from the PHE are set to expire at the end of 2024. If no new legislation is passed, telehealth services could revert to the more restrictive pre-PHE levels, significantly limiting what can be provided. This has major implications for long-term care, where telehealth has become a key care delivery method. While there is an expectation that Congress may extend the current flexibilities, there’s no guarantee. Providers and facilities utilizing telehealth should closely monitor developments.

Under the current provisional CPT code list for 2024, group therapy (97150) remains eligible for telehealth billing. However, other services, like manual therapy and modalities, are not included. These exclusions highlight the limitations of telehealth, even with expanded allowances. If you’re providing telehealth services, it’s essential to familiarize yourself with the requirements, as they remain stringent despite the expanded access. Providers must use HIPAA-compliant, two-way, interactive audio-visual systems—FaceTime and similar non-secure platforms are unacceptable. Sessions must be conducted in real-time, with documented patient consent and meticulous records, including times, locations, individuals involved, and the appropriate modifiers for tracking.

The provisional CPT code list is updated annually, and tracking these changes is crucial. Additionally, while not altering reimbursement, the modifiers added during billing serve to document telehealth services for auditing and regulatory purposes.

Telehealth’s future in long-term care, particularly for group therapy, is still uncertain. While it’s clear that telehealth has established its place in healthcare delivery, the model’s long-term sustainability, regulatory framework, and reimbursement policies remain in flux. Staying informed about evolving regulations and requirements is essential for facilities and providers navigating this landscape.

Tracking of Therapy Minutes

As I mentioned earlier, we are required to track and record the provision of various therapy delivery models. This includes documenting the number of individual therapy minutes therapists provide and the volume of concurrent, group, and co-treatment sessions. These metrics are entered into the Minimum Data Set (MDS), a critical component of long-term care documentation.

For those unfamiliar, the MDS stands for Minimum Data Set and is a standardized assessment tool required for any facility participating in Medicare or Medicaid programs. This includes about 95% of skilled nursing facilities in the United States. The MDS involves comprehensive assessments for all patients, including those in the facility's long-term and short-term rehabs. For long-term residents, assessments are completed on a specific schedule—typically upon admission, quarterly, and annually. For short-term rehab patients, assessments are generally completed at admission and discharge, with occasional Interim Payment Assessments (IPAs) when warranted.

The MDS includes over 500 different data points about each patient, encompassing a wide range of information. While therapists don’t need to be familiar with every detail, there are specific sections where therapy documentation is directly or indirectly involved. Therapy minutes, for instance, are documented in Section O, while functional assessments, a critical area for therapists, are recorded in Section GG. Many therapists in long-term care are familiar with Section GG, but its specific rules and details often go underappreciated.

For any therapist working in long-term care, I strongly recommend obtaining a copy of the Resident Assessment Instrument (RAI) manual. This manual contains detailed instructions for completing the MDS, including guidance on documenting therapy minutes, understanding individual, concurrent, group, and co-treatment rules, and completing Section GG functional assessments. While the manual is extensive—spanning roughly a thousand pages—you don’t need to know it all. Instead, focus on the sections most relevant to your role, such as Sections O and GG.

The RAI manual is updated annually, so ensuring you’re working from the latest version is essential. It serves as the definitive source of truth for anything related to long-term care reimbursement and documentation, providing clarity on accurately assessing and recording patient information. Having the manual as a reference is invaluable, even if you don’t memorize every detail. It ensures your documentation aligns with regulatory requirements, supporting compliance and patient care records' accuracy.

Evolution and Impact of Group and Concurrent

Before we discuss where we are regarding group and concurrent uses and research, let's consider where we've been and where things have gone, especially regarding Medicare. 

CMS Evolution

Medicare was established in 1966, following President Johnson's signing of a bill into law in July 1965. This led to the creation of Medicare and Medicaid as we know them today. The original program consisted of Part A, hospital-based insurance, and Part B, medical insurance. Together, these are what we typically refer to when discussing "original Medicare."

Since its inception, Medicare has undergone numerous changes. Initially, there were 19 million enrollees, a significant number at the time, though it has grown exponentially since then. While we won’t delve into all the changes here—an extensive topic covered in detail elsewhere—it’s essential to recognize that Medicare has historically operated as a cost-based system and has faced ongoing challenges in controlling spending. Headlines warning of Medicare nearing insolvency or running out of funds have been a recurring theme.

One of the significant milestones for therapy was the Balanced Budget Act of 1997. This legislation introduced the prospective payment system (PPS), a shift from the previous reimbursement methods. For skilled nursing facilities (SNFs), this meant receiving a fixed daily rate for Medicare patients based on the RUG (Resource Utilization Group) classification system. This rate was intended to cover nursing care, therapy, and room and board.

The RUG system evolved over the years, creating financial incentives tied to the volume of therapy provided. Facilities received more money depending on the amount of therapy delivered, as reimbursement was based on a per-day rate. This model shaped therapy practices for decades and laid the groundwork for subsequent changes in reimbursement methodologies.

Problems With PPS

Under the RUG system, there was a clear financial incentive to keep patients in skilled nursing facilities (SNFs) as long as possible, with little emphasis on the outcomes achieved during their stays. Those who practiced prior to the Patient-Driven Payment Model (PDPM) are likely familiar with the RUG-IV levels and could probably recite the cutoffs for the different therapy classifications. These levels were broken into Low, Medium, High, Very High, and Ultra High, each defined by specific therapy volumes:

• Low required three days of therapy plus some restorative nursing.
• Medium required five days of therapy, with total therapy minutes between 150 and 324 per week.
• High also required five days of therapy, with 325 to 499 minutes per week.
• Very High required five days of therapy, with 500 to 719 minutes per week.
• Ultra High required at least five days of therapy, with one discipline providing therapy five times a week and another at least three times a week, totaling more than 720 minutes.

These minutes were distributed among therapy disciplines as facilities saw fit. The structure created a clear incentive: more therapy, provided for as long as possible, resulted in the highest reimbursement. This system strongly influenced practices in a largely privatized healthcare sector, where reimbursement parameters often drive decisions.

From 2002 to 2015, data from the PPS era illustrates this trend. The number of SNF days classified as "high group" (500 or more minutes per week, with at least five days of therapy) increased significantly, from 29% of total days to 82%. Similarly, the highest category, Ultra High (720 or more minutes per week), rose from 49% of total days to 57%.

This dramatic rise in therapy minutes occurred without any observable change in patient acuity. Patients were not presenting with more complex conditions or additional therapy needs, yet the volume of therapy delivered steadily increased. While multiple factors likely contributed to this trend, financial motivation was undoubtedly significant. This illustrates how the reimbursement model under PPS shaped care delivery, often prioritizing volume over outcomes.

Thresholding

Thresholding is a term that many who practiced under PPS are probably very familiar with. It essentially refers to strategically hitting the minimum amount of therapy required to reach a higher reimbursement tier without exceeding it unnecessarily. For example, under the RUG system, the threshold for Ultra High was 720 minutes per week. Thresholding would mean delivering 722 minutes—just over the minimum—but avoiding, say, 750 minutes, which wouldn't yield additional reimbursement despite the extra therapy provided. Similarly, for the High category, the threshold was 500 minutes, and providers might deliver 501 minutes to secure the higher rate.

The financial incentive for thresholding directly resulted from operating in a privatized healthcare model. Organizations naturally sought to maximize efficiency and revenue, especially those with tighter margins, such as for-profit facilities or contract therapy providers. These groups were more likely to engage in thresholding as a necessary strategy to stay financially viable. In contrast, nonprofits, facilities with in-house staff, or those with more financial stability tended to threshold less.

However, studies, such as those by Przezynski et al., have shown that higher rates of thresholding are often correlated with poorer outcomes. Facilities engaging heavily in thresholding tended to have lower rates of functional improvement, fewer community discharges, and higher readmission rates. These findings highlight the unintended consequences of a system that incentivized volume over outcomes. While financial motivations were understandable, given the system's structure, the impact on patient care and the profession's reputation was significant.

Another trend seen during this period was excessively long plans of care. Medicare Part A allows up to 100 days of subacute rehab in SNFs, and it became common for more patients to utilize the full 100 days, regardless of their actual needs. This practice led to benefit exhaustion, increased costs, and an overutilization of services. These extended stays, like thresholding, were often driven more by financial incentives than clinical necessity.

These practices resulted in a significant devaluation of the therapy profession. Data analyses began to show that the amount of therapy delivered had no measurable impact on patient outcomes. This statistical conclusion undermined the perceived value of therapy, creating a narrative that therapy made little difference—a perception many therapists found deeply frustrating.

This devaluation had broader implications for the profession. By the time I graduated in 2011 and entered the field, long-term care had developed a significant stigma. In school, we often heard that SNFs were where "good therapy goes to die." They were seen as places delivering low-quality care, rife with unethical practices, and unattractive for new graduates. While some of this stigma was earned, it largely stemmed from systemic issues tied to the reimbursement model.

For me, the impact of this perception felt personal and frustrating. It was disheartening to see the profession I had just entered being undervalued and misunderstood. While I’ve always valued data and metrics, it’s clear that a system focused solely on financial incentives and metrics without prioritizing outcomes can skew perceptions and undermine a profession's credibility. Recognizing and addressing these systemic flaws is critical for creating a healthcare model that balances financial sustainability with high-quality, outcome-driven care.

Problems With PPS, cont.

I blame the PPS system for some of the devaluation and stigmatization of the SNF setting. It’s an incredibly important setting where we care for some of the most vulnerable people in the world. SNFs represent our industry's most regulated component and profoundly impact the quality of life, dignity, and functional independence. For many of these patients, we are the last line of defense in determining whether they go home, remain in an SNF, or what the quality of their life will look like. Our role in this setting is critical and deeply connected to patient outcomes.

Unfortunately, the PPS system diminished the value of this work. The system did not reward high-quality care or good outcomes. Instead, the focus was on therapy volume as the primary driver of reimbursement, which overshadowed the true purpose of care.

In response to these challenges, we saw significant changes during the 2010s. The IMPACT Act (Improving Medicare Post-Acute Care Transformation Act) was one of the most pivotal. This legislation laid the groundwork for the Patient-Driven Payment Model (PDPM). The IMPACT Act aimed to standardize data collection across all post-acute care settings, including inpatient rehabilitation facilities (IRFs), SNFs, home health, and outpatient therapy. It also addressed the critical flaws in the previous reimbursement model, which incentivized therapy volume over patient needs.

The creation of PDPM was a direct attempt to resolve these issues, shifting the focus from quantity to quality. By removing the volume-based incentives and emphasizing patient-driven care, the new model sought to realign the system with its original purpose: improving patient outcomes and ensuring care is tailored to individual needs. This transition marked a significant step in addressing the shortcomings of PPS and reshaping the SNF setting into one that rewards meaningful, patient-centered care.

PDPM

With the introduction of PDPM in 2019, the focus shifted dramatically from therapy volume to clinical characteristics and patient needs as the primary drivers of payment. The intent was to improve reimbursement accuracy while incentivizing high-quality, patient-centered care over the sheer volume of service delivery.

Under the previous system, the amount of therapy provided directly influenced a significant portion of the per diem payment or daily rate. PDPM completely changed that. Instead, reimbursement is calculated using a complex formula for patient presentation, diagnostic groupings, and case mix-adjusted components. These components include physical therapy, occupational therapy, speech-language pathology, non-therapy ancillary (NTA) services, nursing, and a non-case-mix-adjusted component. This formula determines the daily rate, adjusted over time during the patient's stay.

The payments are tied to the patient’s characteristics and expected needs based on their diagnosis and presentation, not the volume of services delivered. While this formula can seem complicated, it’s worth exploring if you’re unfamiliar. Understanding the factors that influence reimbursement can provide valuable insight into how the system operates.

One of the most significant changes under PDPM is the decoupling of therapy delivery from reimbursement. Many assume that the PT, OT, and SLP case mix-adjusted components mean therapy must be provided to justify payment. However, that’s not the case. A facility can receive reimbursement for these components even if no therapy is provided, which understandably creates confusion. While therapy is still critical for patient outcomes, it is no longer directly tied to the payment model under PDPM.

Bringing this back to group therapy, our focus here, this shift has important implications for how group therapy is utilized and valued in patient care and reimbursement.

PPS

Prior to PDPM, group therapy under the PPS system was defined as four residents performing the same or similar activity, regardless of their payor source, under the supervision of a therapist or assistant who was not simultaneously supervising any individual treatments. While this definition is somewhat similar to the current understanding of group therapy, the key distinction was the requirement of four residents.

The most notable aspect of group therapy under PPS was how the recorded therapy minutes were handled on the MDS. The total time spent in the session was divided by four, reflecting that the therapist provided group therapy to four individuals. This division meant that, from a reimbursement perspective, group therapy did not yield any efficiency or financial benefits. While it could still offer clinical benefits—such as addressing care needs for multiple patients simultaneously or providing a therapeutic environment that leveraged social or motivational factors—it didn’t incentivize facilities to utilize group therapy.

Because the reimbursement under PPS was tied to the total therapy minutes delivered, splitting the time across four residents significantly diluted its impact. As a result, group therapy wasn’t commonly used, as it offered no financial advantage. This lack of incentive left it underutilized, even if it had clinical value in certain scenarios. This historical context is important when considering the shifts in how group therapy is perceived and utilized under PDPM, where financial and operational considerations have evolved.

Transition from RUGS IV to PDPM

The transition from the RUGs PPS system to PDPM was monumental and caused significant anxiety across the industry. Facilities faced the uncertainty of an entirely new reimbursement model, fearing it might threaten their financial stability. Many were concerned about whether their income streams would remain sufficient, and unfortunately, some facilities did not survive the transition.

The shift was equally unsettling for therapists, as it was unclear how this new model would impact therapy delivery and job security. Personally, I stepped into my first role as a rehab director just before PDPM was implemented. The director before me, who had been in the role for many years and was performing well, chose to retire early, citing the looming challenges and complexities of PDPM as the tipping point.

In preparation for PDPM, my team and I tried to anticipate its effects and adapt our approaches. Knowing that reimbursement was no longer tied to therapy volume, we recognized the need to deliver therapy only where it was clinically necessary and likely to have the most significant impact. Any unnecessary therapy would now be a financial liability. This forced us to rethink our models of care entirely.

We experimented with scenarios based on patient presentations, prior functional levels, and expected progress. For instance, we might recommend four days of PT, five days of OT, and one session of SLP per week for one patient, while another might receive two weeks of one discipline followed by another carrying the remainder of the plan. We tried to align our decisions with what would produce the best outcomes while staying efficient and cost-effective. However, these decisions were largely guided by anecdotal knowledge and personal experience since little evidence-based guidance was available at the time.

When PDPM officially launched, it was challenging but manageable—until a few months later, when the public health emergency due to COVID-19 upended everything. In long-term care, the structured plans and careful approaches we had developed were quickly rendered irrelevant. The focus shifted from optimization to survival as we navigated unprecedented challenges in patient care, staffing, and overall facility operations. PDPM was no longer the biggest concern; the pandemic reshaped priorities entirely, forcing us to adapt in ways no one could have anticipated.

Key PDPM Changes

The transition to PDPM brought some significant takeaways regarding reimbursement and therapy approaches, and I will highlight three major ones.

First, under PDPM, group and concurrent therapy are now fully counted toward therapy minutes without being divided among participants. This was a big shift from the RUGs system, where minutes were split between participants in a group session. Now, a therapist can provide a 60-minute group session to four patients, which counts as four hours of therapy time, even though it only requires one hour. This creates financial efficiency, making group and concurrent therapy much more appealing from a resource utilization standpoint. However, there’s a cap: no more than 25% of total therapy minutes per discipline per covered stay can be provided through group and concurrent therapy combined. Each discipline must stay below this 25% threshold.

Second, reimbursement under PDPM is tied to the patient-specific reimbursement rate rather than the volume of therapy delivered. The daily rate remains constant regardless of whether a patient receives minimal therapy, such as 20-minute sessions five times a week or significantly more, like 200 minutes per discipline six days a week. This decoupling of therapy volume from reimbursement incentivizes providing therapy based on clinical need rather than a financial target, encouraging efficiency and patient-centered care.

Lastly, the per diem daily rate under PDPM decreases over time. Payments are front-loaded, with higher rates at the start of a patient’s stay, reflecting the expectation that more resources are typically required early in the rehabilitation process. As the stay progresses, the daily rate steadily reduces, incentivizing facilities to discharge patients efficiently and avoid unnecessarily prolonged stays.

These changes shifted the focus from therapy volume to clinical decision-making, encouraging more efficient use of therapy resources while aligning care with patient-specific needs. However, they also introduced challenges, requiring facilities to balance clinical outcomes with operational and financial considerations carefully.

Calculating Group/Concurrent Therapy Limit

This is essentially a straightforward calculation of how the 25% threshold for group and concurrent therapy is determined under PDPM. CMS monitors compliance with this limit for each discipline as part of the discharge MDS assessment. While they’ve stated they monitor for significant shifts in group and concurrent usage or decreases in therapy minutes, this isn’t enforced very stringently unless outcomes are notably impacted.

Let’s break down the example calculation:

If, during a patient’s stay, you provided:

• 2000 minutes of individual PT
• 600 minutes of concurrent PT
• 1000 minutes of group PT

The total number of PT minutes would be 3600. Of these, 1600 minutes (600 concurrent + 1000 group) were delivered in multi-participant formats. To calculate the percentage, divide 1600 by 3600, then multiply by 100. This yields 44% of PT minutes provided under group or concurrent therapy, which exceeds the 25% threshold.

If this occurs, a non-compliant warning message will appear on the discharge assessment validation report, signaling that the facility has exceeded the allowable limit. There is no direct penalty for this non-compliance; however, CMS has indicated that facilities consistently exceeding the limit may be subject to audits or penalties. While I haven’t personally encountered facilities in my region facing serious consequences, such instances have likely occurred elsewhere in the industry.

Facilities typically monitor group and concurrent minutes throughout the plan of care to avoid exceeding the threshold. Most organizations track each patient's allowable group therapy minutes to prevent going over the limit. However, issues can arise in practice, such as sessions running longer than planned, resulting in unintentional overages. Additionally, unexpected discharges can lead to non-compliance, as facilities lose the opportunity to balance out group therapy minutes with additional individual therapy. This non-compliance is often unintentional and reflects the challenges of managing therapy plans in real-world scenarios.

Group and Concurrent Evolution

The delivery of group and concurrent therapy underwent significant changes with the transition to PDPM. Prior to PDPM, these formats were rarely utilized due to the lack of financial incentives. Data shows that only about 1% of all SNF stays included any documented group or concurrent therapy sessions under PPS. Group sessions were generally reserved for situations where facilities were short-staffed and needed to ensure residents were seen, as there was no reimbursement advantage.

When PDPM was introduced in October 2019, allowing up to 25% of therapy minutes to be delivered via group or concurrent formats, utilization of these models increased sharply. In the first month of PDPM, the percentage of SNF stays that included any group or concurrent therapy rose from 1% to nearly a third. However, this figure reflects the percentage of stays with some group or concurrent therapy utilization, not the total percentage of therapy minutes delivered in this way.

The onset of the COVID-19 pandemic just months later abruptly disrupted this shift. Isolation precautions and restrictions on group activities caused a dramatic decrease in group and concurrent therapy. This interruption likely altered how these therapy models would have evolved under PDPM, as facilities shifted their focus to infection control and patient safety rather than optimizing therapy delivery models.

With these changes, CMS would monitor how therapy delivery models evolved under PDPM. They warned against significant drops in therapy minutes or excessive shifts toward group and concurrent formats but did not provide clear thresholds for what constituted "too much." Despite these warnings, major shifts did occur. Medicare released data indicating that increased use of group and concurrent therapy and reductions in therapy minutes did not negatively impact outcomes. CMS reported no connection between higher group and concurrent usage or reduced therapy minutes and worse patient outcomes, although they pledged to continue monitoring.

However, other findings contradicted CMS's conclusions. For example, the APTA and AOTA’s TOPS (Therapy Outcomes in Post-Acute Care Settings) joint study found a correlation between therapy intensity and volume and patient outcomes, suggesting that fewer therapy minutes could lead to lower outcomes. Anecdotally, many clinicians observed similar trends, where patients who received fewer minutes of therapy achieved poorer outcomes, mirroring the TOPS study findings.

Over time, these initial disruptions appear to have stabilized. Facilities and therapists have likely adapted to the PDPM model, improving outcomes with the available resources and frameworks. While the gap between reduced therapy minutes and patient outcomes has flattened, it remains to be seen whether the long-term impact of these changes aligns with the initial goals of PDPM. The balance between financial efficiency and maintaining high-quality, patient-centered care continues to be an area of focus and evolution.

Impact of Group and Concurrent

Returning to group and concurrent therapy, CMS concluded that increased group therapy usage under PDPM had no negative impact. Interestingly, accrediting bodies such as APTA and AOTA did not contradict CMS, unlike their position on reduced therapy minutes. Instead, they appeared to align with the idea that group and concurrent therapy could have potential benefits when used appropriately.

That said, accrediting bodies remain cautious about how these formats are utilized. They emphasize that group and concurrent therapy should be employed based on clinical reasoning and the patient's specific needs. While there is a growing body of research exploring the impacts of group and concurrent therapy—research that we’ll review later—these organizations have struggled to provide definitive guidance. This is largely due to a lack of comprehensive, high-quality studies that definitively outline best practices for these therapy formats. As a result, the recommendations focus on ensuring that group and concurrent therapy are used judiciously and in ways that genuinely benefit the patient’s rehabilitation process.

Therapist Impact

The transition to PDPM understandably raised significant concerns within the therapy field, particularly regarding job security. With therapy volume no longer dictating reimbursement, many therapists worried about how their roles would be impacted. The concern was especially acute in facilities that had previously aimed to maximize ultra-high RUG categories and stretch rehab stays to 100 days regardless of clinical need—practices that were already ethically questionable under the RUG system. Under PDPM, the fear was that these facilities might shift their focus to minimizing therapy delivery, maximizing group and concurrent therapy, and cutting staffing to reduce costs.

In some cases, these fears were realized. There were reports of immediate reductions in Part A therapy utilization, leading to decreased staffing needs. The introduction of group and concurrent therapy, which requires fewer staff resources, further contributed to this trend in certain facilities. Some SNFs reported layoffs and imposed new mandates to heavily use group and concurrent therapy—decisions that were often driven by financial motivations rather than clinical appropriateness. This approach contradicted PDPM’s intent to prioritize patient-centered care over cost-cutting.

That said, these changes were not uniform across the industry. Facilities varied widely in their responses, with some making only minor adjustments to therapy delivery while others implemented drastic shifts. The changes reflected differences in organizational culture, financial stability, and commitment to ethical care. While some facilities may have leaned too heavily into reducing therapy under PDPM, others maintained a balanced approach, focusing on delivering the right care at the right time, even within the new reimbursement framework.

Impact of Group and Concurrent

Staffing levels across therapy disciplines experienced modest reductions immediately following PDPM implementation. From October to December 2019, post-PDPM but pre-PHE, overall therapy staffing decreased by about 5-6%. Evaluator roles—such as occupational and physical therapists—saw reductions in line with this average. However, therapy assistant roles, including occupational and physical therapy assistants, experienced sharper declines, with staffing levels reduced by approximately 10%. Nursing staff, by contrast, did not see significant changes during this period, though ongoing nursing shortages remained a persistent issue.

The landscape shifted dramatically with the onset of the COVID-19 pandemic. Healthcare professionals in long-term care faced unprecedented challenges, leading to significant attrition. Many left for higher-paying opportunities outside long-term care, while others departed due to burnout, fear of COVID exposure, or frustration with working conditions. These factors collectively caused a seismic staffing disruption across healthcare.

The most pronounced reductions were observed in contracted facilities. Contract therapy providers, which operate under tighter financial constraints, were particularly impacted. These organizations often needed to make swift adjustments to align payroll with revenue, leading to deeper therapy staffing cuts. Their reliance on cost efficiencies made them more vulnerable to the economic shifts brought on by both PDPM and the pandemic, further highlighting the financial pressures of maintaining staffing in a challenging reimbursement and care environment.

Best Practice Guidance and Current Research

Best practices are always the focus, yet they’re one of the most challenging concepts to define. Organizations like the APTA strive to provide guidance on best practices, but these recommendations are continuously evolving. Best practices today often reflect an attempt to merge two seemingly opposing yet complementary trends: standardization of care and individualization of treatment.

Standardization involves using objective tools, evidence-based methods, and risk stratification to guide therapy decisions, particularly around specific conditions. It ensures consistency and relies on established frameworks to deliver effective care. On the other hand, individualization emphasizes tailoring care to each patient’s unique presentation, goals, and circumstances. This includes understanding their personal objectives, which may not align neatly with standard guidelines, and adapting to comorbidities, motivation levels, or cognitive impairments.

Merging these two approaches—standardization and individualization—is inherently difficult. Especially with older adults in long-term care, the complexity of multiple conditions, dementia, and varying levels of engagement requires clinicians to think beyond textbook definitions. Aligning patient goals with therapeutic objectives often involves nuanced, patient-centered decision-making.

Best practice also evolves over time. How we rehabilitate a total knee replacement today is markedly different from 20 years ago, and it will continue to change. As clinicians, we must remain adaptable, continuously integrating new research and methods while critically evaluating their application.

As we delve into the research and data around group and concurrent therapy, we must approach the topic with an open mind. We must be willing to consider practices that differ from what has been done in the past. At the same time, we must maintain a healthy skepticism—particularly when financial incentives are at play. Just because something offers a financial benefit doesn’t mean it lacks clinical value, but critically examining the evidence supporting its efficacy is important.

Ultimately, there’s unlikely to be a step-by-step gold standard for best practice in newer areas of therapy. Instead, best practice thoughtfully combines the available resources and evidence with sound clinical decision-making. It’s about balancing what we know with the realities of the patient in front of us, recognizing that our role is to adapt and refine our approaches continuously.

General Group Exercise Literature

Before diving into group rehabilitation specifically, it’s worth noting that there’s been extensive research on group exercise in general. While this might not be the exact same as what we do in rehabilitation, the principles and findings are still relevant.

For instance, many of us can relate to the dynamics of group exercise, whether we’ve participated in it personally or observed its effects on others. As someone who tends to be more introverted and prefers exercising individually, I’ve still experienced the unique benefits of group exercise. In fact, some of the times I’ve been in the best shape—both stronger and faster—were when I was training in a group format.

Group settings often provide motivation, accountability, and a sense of community that can be difficult to replicate in individual sessions. These factors are central to why group exercise has improved adherence and outcomes in various populations and why we see similar benefits in group rehabilitation settings. Understanding these broader dynamics helps frame the discussion as we move into the specifics of how group rehabilitation is applied in therapy.

Comparison of Perceived Benefits

Research widely recognizes and supports the benefits of group exercise, and they extend to the context of group rehabilitation. In a group setting, participants often experience socialization, the ability to observe and learn techniques from others, motivation through a sense of competition or shared goals, and accountability to the group. These dynamics create objective and subjective benefits, making group exercise effective in many contexts. Importantly, research on group exercise reflects these advantages, with only a handful of drawbacks noted.

From a therapy perspective, when deciding how to structure clinical delivery models, the critical consideration is whether a particular approach supports or detracts from outcomes. Even if a model has financial benefits, if it negatively impacts patient outcomes, it undermines the long-term success of a therapist or therapy organization. Positive outcomes are essential for maintaining professional integrity and achieving sustainable success in the field.

When comparing individual and group formats for exercise—whether in general or specifically in therapy—both have distinct advantages and drawbacks. The key benefits of individual therapy or exercise include tailoring the session to the individual’s specific needs, maintaining confidentiality, customizing intensity and pacing, and providing detailed feedback and communication based on personal preferences.

Group therapy or exercise, on the other hand, offers shared support and socialization, reduced individual pressure, visual modeling and feedback, and, in many cases, greater cost-effectiveness. It can also mimic real-world scenarios, where individuals are likely to engage in activities with others rather than in isolation. Additionally, in rural or underserved areas with limited staffing, group therapy can be a practical way to maximize resources while delivering meaningful care.

The choice between individual and group delivery in therapy often depends on the patient population, available resources, and specific treatment goals. Each approach has its place, and the challenge lies in striking the right balance to optimize clinical outcomes and resource efficiency.

When to Perform Group?

The question of when to perform group therapy is critical, and there hasn’t historically been a wealth of guidance available on this topic, especially prior to PDPM. Back then, neither APTA nor CMS offered much in the way of clear recommendations or structured guidelines on how and when to utilize group and concurrent therapy sessions. It was largely left up to therapists to decide.

Under PDPM, CMS's general stance is that group and concurrent therapy should only be provided when the resident will genuinely benefit from it. APTA echoes this perspective, but the challenge lies in defining and determining what constitutes "benefit." Without clear metrics or a one-size-fits-all approach, the decision often feels subjective and reliant on the clinician’s judgment.

To address this, APTA has provided a basic decision tree to help guide these choices. The framework involves asking a few key questions:

• Can the intervention be considered to be provided using group therapy to achieve the patient’s plan of care goals?
• Will group therapy provide a value-added benefit or enhance the patient’s experience?
• Is the individual open and willing to participate in a group setting?

This structure offers a starting point, but it still leaves room for interpretation. For instance, determining whether group therapy provides a "value-added benefit" can often feel opinion-based rather than rooted in objective criteria. Without clear tools or research to guide this assessment, clinicians may find themselves relying on their judgment or referencing the general benefits of group therapy, such as socialization, motivation, and cost-effectiveness.

Even those proposed benefits, as discussed earlier, are not always supported by robust research and may be more anecdotal in nature. While they can serve as a helpful reference, they aren’t necessarily grounded in evidence specific to therapy outcomes. As a result, decisions about when to use group therapy often come down to individual clinical reasoning, which can vary widely from therapist to therapist.

The lack of definitive, evidence-based guidance underscores the need for continued research and discussion around the most effective ways to integrate group therapy into care plans. Until more concrete frameworks are available, clinicians must carefully weigh the potential benefits against each patient's unique needs and preferences.

Best Practice Guideline

The challenge of determining when to perform group therapy lies in the absence of a gold standard or clear evidence-based guidelines. This leaves much of the responsibility on clinical decision-makers to determine when and how to incorporate group therapy effectively. However, in long-term care—where group therapy was rarely utilized before PDPM—this reliance on clinical decision-making can be problematic. Many therapists, having limited experience with group therapy in this setting, may lack the foundation to confidently decide who will benefit and how to implement it appropriately.

Without a robust evidence base, decisions are often influenced by anecdotal experience. If group or concurrent therapy wasn’t part of a therapist’s prior practice, it’s challenging to draw on personal experience to evaluate its potential benefits. This creates a significant gap, leaving therapists to navigate new territory with minimal guidance.

Suggestions for when to prioritize individualized therapy include:

• Functional goals requiring hands-on physical assistance.
• Higher acuity patients or those with more complex medical needs.
• Cognitive impairments, where the ability to benefit from group interaction may be questioned.

However, cognitive impairments in long-term care deserve a more nuanced consideration. While it’s true that higher cognitive complexity may sometimes necessitate individualized interventions, there is compelling research suggesting that individuals with dementia or cognitive impairments can benefit significantly from group settings. Participating in group activities may provide visual feedback, social interaction, and a sense of inclusion, all of which can support engagement and motivation.

Interestingly, research also indicates that pairing individuals with lower cognitive levels with higher-functioning peers can have positive effects on the person with greater impairment. The higher-functioning individual serves as a model, offering socialization and observational learning opportunities. While there could be potential drawbacks for the higher-functioning individual—such as frustration or a slower pace—these challenges must be weighed against the benefits to the group dynamic.

Ultimately, the lack of a clear framework underscores the need for further research and training in this area. Therapists need tools to help them identify candidates for group therapy and understand its potential advantages in the long-term care population. In the meantime, clinical decision-making should remain patient-centered, considering not only functional goals and acuity but also the broader psychosocial benefits that group therapy can provide.

What is the Right Size Group?

Determining the "right" size for a group therapy session is a nuanced decision, particularly given the broad parameters allowed under Medicare. For Part A, the group size can range from 2 to 6 participants, while Part B has no defined upper limit. However, the practical differences between managing a two-person group and a six-person group are substantial, even though their billing and guidance remain the same.

Currently, the decision on group size is left to clinical judgment, with general considerations such as safety, engagement, and challenge level serving as guiding principles. Specifically, therapists are encouraged to ask:

• Is it safe to conduct a group of this size, given the patients' needs and physical abilities?
• Can all participants be actively engaged throughout the session?
• Can the group size allow each patient to be appropriately challenged and supported?

These considerations are important but remain subjective, as they rely heavily on the therapist’s judgment and experience rather than concrete, research-based guidelines. There is no established gold standard or evidence to definitively guide group size selection, leaving decisions rooted in personal experience and anecdotal knowledge.

In practice, smaller groups may allow for more individual attention and closer monitoring, making it easier to ensure safety and engagement. Larger groups, on the other hand, can create a dynamic environment with opportunities for socialization and peer modeling, but they also increase the complexity of managing the session and tailoring interventions to diverse needs.

This lack of clear, research-backed guidance highlights the need for further studies to determine optimal group sizes for different patient populations and therapy goals. Until more evidence becomes available, therapists must continue to rely on their clinical reasoning and adaptability, considering factors like patient acuity, therapeutic goals, and logistical constraints when deciding on group size.

When Not to Perform Group Therapy

There are some clear situations where group or concurrent therapy may not be appropriate, and many of these are fairly intuitive. For instance, if a patient is under restrictions or isolation precautions, group therapy is generally not feasible. That said, concurrent therapy has been successfully provided for cohort groups of patients on similar restrictions, though this requires careful consideration and planning.

Patient preference is another critical factor. While we should always defer to a patient’s choice, we must also ensure they are fully informed about the potential benefits of group or concurrent therapy. Just as we might educate a patient who is reluctant to participate in therapy altogether, we should explain the specific advantages of group or concurrent formats, such as socialization, motivation, and enhanced engagement, to help them make an informed decision. Ultimately, that choice must be respected if they still choose not to participate.

Safety concerns are another important consideration, especially for patients with significant cognitive impairments or those who require substantial physical assistance. While arguments can be made for including lower-functioning individuals in group therapy—such as the benefits of socialization and visual modeling—there are limits to what can be managed safely in a group setting. Deciding where that line is drawn often comes down to clinical judgment.

Finally, the potential impact on the effectiveness of care must be weighed. If a patient requires frequent one-on-one cues or physical contact to perform tasks correctly or safely, it’s clear that their needs may not be adequately met in a group format. In such cases, the effectiveness of therapy could be compromised, making individual therapy the more appropriate choice.

These considerations highlight the complexity of deciding when not to provide group or concurrent therapy. While there are some obvious situations where these formats are unsuitable, many decisions ultimately rely on the therapist’s clinical reasoning, balancing patient needs, safety, and therapeutic goals.

Current Group Usage

Looking at how group and concurrent therapy is currently applied, we see a lot of variability in its use, format, and quality. Despite the guidance tools we’ve discussed, much of the decision-making still heavily relies on individual clinical judgment. In practice, the application of group therapy fluctuates significantly across facilities. From my experience visiting dozens of clinics across multiple states, the differences in how group therapy is provided—its intensity, format, and quality—run the full spectrum, reflecting inconsistencies in approaches beyond just group therapy.

Although some studies were conducted post-2019, our research predominantly relies on pre-PDPM data, where only about 1% of cases included group or concurrent therapy. While these data sets are large enough to provide valuable insights, they’re limited in applicability due to the major changes in therapy practices introduced with PDPM. The studies offer some interesting takeaways and point to areas for further research on post-PDPM practices.

One relevant study conducted by Przysncall examined the factors influencing decisions to use group therapy. The findings revealed that organizational characteristics of skilled nursing facilities had a stronger impact on whether group therapy was provided than patient-specific factors. This aligns with the lack of clear guidance on patient-centered criteria for group therapy. Key organizational factors included:

• For-profit facilities have higher rates of group therapy use.
• Facilities with higher therapy volumes and a larger proportion of assistants and contract staff utilize more group therapy.

It’s worth noting that this data was collected pre-PDPM when there was no financial incentive for providing group therapy.

Another study by Gustafson et al identified additional factors influencing group therapy use. They found that patients who were private pay or managed care were more likely to receive group therapy, while those with traditional Medicare or high pain levels were less likely to participate in group sessions. Importantly, they found no significant difference in functional outcomes—including SPPB scores, gait speed, or other measures—between group therapy and individual therapy. While this suggests group therapy did not negatively impact these outcomes, it’s also a reminder that group therapy alone didn’t improve functional outcomes relative to individual therapy in these measures.

The research highlights a broader concern: the low functional improvement rate in SNFs. One study noted that about 40% of individuals admitted to SNFs for rehabilitation made no significant functional gains and did not return home. This raises questions about the quality of care provided pre-PDPM and the potential for improvement in therapy delivery models.

While pre-PDPM data has limitations, it underscores the need for post-PDPM research to better understand how group and concurrent therapy can be optimized to improve outcomes. The variability in how therapy is applied and the lack of consistent guidance remain ongoing challenges that require thoughtful consideration and study.

Research on The Value of Group Rehabilitation

There is a significant amount of research on the benefits of group therapy, much of which has been consolidated by the APTA over the years. These resources provide valuable insights into specific patient populations and conditions where group therapy can be effective. While it’s impossible to go into the details of each study here, it’s worth noting the general categories and patient presentations supported by this research. If any of these align with your clinical practice, I encourage you to consult the original studies for more in-depth information, many of which are available through the APTA.

Group rehabilitation is equally effective as individual therapy for patients with rotator cuff repairs, achieving similar improvements in active range of motion and functional outcomes. In the context of fall prevention, group therapy paired with interdisciplinary fall risk assessments, including exercise and education, has demonstrated sustained gains for patients. Group therapy has been found to strengthen motivation and belief in functional improvement among patients with osteoporosis, emphasizing qualitative benefits.

Group exercise has shown physical, emotional, and psychosocial benefits for individuals undergoing or recovering from cancer treatment. In patients with multiple sclerosis, group therapy has been effective in improving balance, functional status, spasticity, and fatigue while also being safe, feasible, and effective for individuals with various progressive neurological disorders. Among individuals with Parkinson’s disease, group therapy has led to meaningful clinical improvements in mobility and gait measures while also being safe and acceptable for older adults with impaired mobility.

Women with postmenopausal osteoporosis have experienced reduced back pain, improved functional status, and enhanced quality of life with group therapy. In the rehabilitation of patients recovering from traumatic brain injury, group therapy is more effective than individual treatments alone in certain contexts. For conditions such as back pain and urinary incontinence, group therapy has demonstrated equivalent clinical outcomes to individual therapy. It has also been found to be as safe and effective as dose-matched individual therapy for individuals recovering from moderate to severe stroke.

These findings highlight the potential for group therapy to be a valuable and effective approach across various diagnoses and clinical settings. While each study has its own limitations, the overall evidence supports the use of group formats as a complementary or alternative method to individual therapy. For therapists working with any of these patient populations, exploring the specific studies can provide a deeper understanding of how to apply group therapy effectively.

How Much Is Too Much?

Determining how much group and concurrent therapy is "too much" is a nuanced question. We have limited guidance beyond the 25% cap established under PDPM. While the cap gives us a boundary, it doesn’t inherently define best practice or optimal use.

Brzezinski et al.'s notable study explored this question, although it was based on pre-PDPM MDS data despite being conducted post-PDPM. The study utilized a large data set to analyze the implications of therapy volume, particularly in terms of functional improvement and community discharge rates. The key focus was whether exceeding certain volumes of group and concurrent therapy negatively impacted outcomes.

The study broke group therapy usage into categories: low (5%), moderate (5–15%), higher moderate (15–25%), and high (over 25%). The findings indicated that the positive associations between functional improvement and community discharge rates increased as group therapy usage increased, up to 25%. However, beyond 25%, those positive relationships diminished. This suggests a potential threshold where the benefits of group therapy plateau and additional group time no longer contribute to improved outcomes.

It’s important to note that this study was correlational, meaning we can’t definitively conclude that group therapy directly caused the improvements. It’s possible, for example, that patients who received more group therapy were already higher functioning or more likely to be discharged to the community for other reasons. Despite these limitations, the findings offer valuable insights.

When taken alongside the other studies we’ve reviewed, evidence doesn’t appear to suggest that group or concurrent therapy hurts outcomes. While we can debate whether these formats have a distinct positive effect, the data at least supports the idea that they are not harmful when used appropriately. This conclusion aligns with the general guidance from CMS and accrediting bodies, which emphasize ensuring that group therapy is used in clinically beneficial ways.

No valid studies seem to suggest that group or concurrent therapy leads to worse outcomes. While ongoing research is needed to refine our understanding and best practices, the current evidence supports these formats as safe and potentially beneficial therapy components when applied within the appropriate limits.

What is the Current Literature Suggesting?

Summarizing the current literature on group and concurrent therapy, it’s clear that while we don’t yet have a gold standard, there are some emerging trends and suggestions. The first major observation is that current and prior usage patterns of group and concurrent therapy were, and often still are, not primarily driven by patient presentation. This reflects the lack of a well-defined best practice standard that specifies who should receive group therapy, how much they should receive, and in what format.

Despite this gap, the evidence suggests that group and concurrent therapy are generally effective for the majority of patients. The available research indicates that these formats are not harmful and, in many cases, may offer benefits comparable to individual therapy. There are also likely scenarios and specific patient populations where group therapy could be particularly advantageous, though identifying these cases requires more precise guidelines and research.

While a gold standard for when and how to implement group therapy is not yet established, the trends suggest that group formats can serve as a valuable tool in rehabilitation, especially when clinical reasoning and patient needs are carefully considered. These findings will hopefully evolve as research develops into more structured recommendations to guide its optimal use.

Best Practice Takeaways

To summarize the best practice takeaways for group and concurrent therapy, it’s clear that clinical decision-making remains the cornerstone for determining when, how, and to what extent these formats should be used. Given the lack of a definitive gold standard, clinicians must rely on their judgment, which often stems from anecdotal experience. However, it’s important to recognize that the amount of experience with group or concurrent therapy varies widely, and many therapists have had limited exposure to these formats.

While it’s natural to approach group and concurrent therapy with a degree of skepticism, particularly given the financial incentives tied to their use under PDPM, the evidence so far suggests there is value in incorporating these methods. Current research indicates that group and concurrent therapy likely do not negatively impact outcomes for the majority of patients, and in some cases, they may even provide benefits comparable to individual therapy. This makes them a valuable tool, particularly because they can improve efficiency without compromising effectiveness.

For those uncertain about when or how to use group and concurrent therapy, a cautious but proactive approach is advisable. When in doubt, leaning toward using these formats rather than avoiding them altogether can be a reasonable strategy. While we cannot yet say definitively that group therapy benefits every patient, the data suggest it is at least a neutral and potentially positive intervention for most.

It’s also important to recognize that group and concurrent therapy offer a rare opportunity to enhance clinical efficiency and patient care. Few interventions provide the potential to streamline delivery while maintaining or improving therapeutic outcomes. While the suspicion stemming from past practices under PPS is understandable, it’s crucial not to let that suspicion entirely deter the use of these formats. The current evidence indicates that group and concurrent therapy are more than just financially motivated—they hold legitimate value as a tool in therapy practice.

Ultimately, it’s up to each clinician to decide how and when to use group or concurrent therapy, but the trends suggest these formats should be considered a regular part of practice rather than dismissed outright. Balancing skepticism with open-mindedness allows thoughtful implementation that prioritizes patient needs and clinical effectiveness.

Techniques and Barriers for Group Implementation

Bringing this back to the real world, as I mentioned earlier, I’m fortunate to treat only about five hours a week on average, sometimes up to ten or fifteen if I’m assisting on-site. Because of that, I’m not burned out or exhausted from direct patient care time, which gives me the space to think critically about therapy delivery models, including group therapy.

Even personally, I have mixed feelings about group therapy. I know it can be impactful and have had some good success with it in my own practice, but I also find it exhausting to execute well. There are so many barriers to running a group effectively, and while this isn’t a conclusive list, it’s a reminder of the complexities we face in implementing group therapy in real-world settings.

Barriers

This is largely based on my observations and experiences in the field, but group therapy has significant logistical challenges. One major issue is setup, breakdown, and site logistics. Even in individual therapy, I’m already navigating around meal times, nursing visits, overlapping schedules with other therapists, patients’ wakefulness, pain management schedules, and bathroom needs. Adding the complexity of coordinating multiple patients simultaneously makes this exponentially harder.

I aim to be intentional with my intervention choices, ensuring they are tied to functional goals and specific patient outcomes. That’s much more difficult to achieve in a group format. Similarly, I strive to objectively dose my interventions—a concept we’ll touch on later—but this is also more challenging to implement in a group setting.

Point-of-service documentation, which I try to do whenever possible, becomes nearly impossible during group sessions. Instead of documenting as I go, I’m left trying to capture accurate, efficient, and effective notes afterward, which can feel like a compromise between quality and avoiding excessive downtime.

On a personal level, I find running a group physically demanding. By the end of a session, I’m often pretty exhausted. Beyond the logistics, there’s also the barrier of perception. I need to convince other therapists of the value of group therapy, which can be a challenge, especially when there’s skepticism. Convincing patients of its value is another hurdle, ensuring they understand the potential benefits and are fully engaged to maximize the experience.

Let’s break these barriers down further and explore what strategies seem to work in addressing these challenges based on what I’ve seen in the field.

Clinically Managing Group and Concurrent

Overcoming logistical barriers and ensuring group therapy ties directly to functional goals requires planning and intentionality. While some aspects of group therapy may need to be decided on the fly due to daily restrictions and barriers, planning ahead as much as possible tends to yield the best results.

Planning involves two key aspects. First, scheduling the group session on a specific day and time allows you to inform other staff and departments. When others know, for example, that PT runs a group every Friday at 10 a.m., they’re more likely to accommodate and help mitigate disruptions. Second, planning includes outlining the details of the session itself—what interventions will be performed, how they connect to specific functional goals, and what equipment or space is needed. This ensures the group is purposeful and tied directly to the function, such as exercises focused on improving transfers or education sessions that reinforce safety strategies.

Setup time is often a challenge. Without a tech or assistant, organizing a group can feel daunting. Gathering patients, ensuring their needs are met, and avoiding disruptions from nursing or other departments can easily take 20 minutes or more. Planning ahead by communicating with departments, emailing group schedules, or using shared calendars can reduce these delays. Pre-setting the space and equipment also helps streamline the process.

Despite the upfront effort, the efficiency gained from group therapy can outweigh the time spent setting up. For example, a 30-minute group session with four participants effectively delivers two hours of therapy in 30 minutes. This efficiency offsets setup and breakdown time and may allow additional documentation time after the session. Coordination with other therapists is another useful strategy. Communicating plans can help dovetail treatments, allowing one therapist to transition patients into a group session seamlessly.

Given the shorter treatment times under PDPM—around 30 to 35 minutes on average compared to the 70 to 75 minutes often seen under PPS—every intervention must count. This shift mirrors the approach you’d take if, for instance, you were going to the gym with less time but the same goals. You’d focus on exercises with the highest impact, perform them at a higher intensity, and ensure consistent progression. The same principle applies to therapy. Intervention choices must deliver the highest clinical impact, be directly tied to functional goals, and be performed at the highest safe intensity to maximize outcomes.

For part A patients, where outcomes are often judged on section GG functional measures, functional treatments are typically the most effective. Even if the intervention isn’t explicitly functional, it should have a clear and direct connection to the patient’s functional goals. For example, if the goal is to improve transfers, interventions should explicitly build strength, endurance, or techniques needed for that task. The more intentional and focused the intervention, the more likely it is to deliver meaningful results within the limited time.

Group Intervention Intensity

Dosing interventions, particularly when it comes to intensity, have not been widely implemented in long-term care, even though they are a more established practice in outpatient and inpatient rehab settings. The dosing concept is rooted in the idea that rehab interventions, like medications, follow a dose-response relationship. An ideal volume and intensity for each intervention are necessary to achieve the desired therapeutic effect.

Consider how medications are prescribed. A physician doesn’t just write a generic prescription; they provide precise instructions on dosage, frequency, and other considerations, such as whether it should be taken with food or adjusted for patient-specific factors like weight. Rehabilitation interventions should follow a similar model. The intensity of exercises, the number of repetitions, and the resistance must be purposeful and tailored to the specific goals and capabilities of the patient. This intentionality ensures that interventions are truly skilled.

Some interventions, like therapeutic exercise and gait training, are more straightforward to dose because their intensity can be measured directly using tools like the Rating of Perceived Exertion (RPE), heart rate, or even percentages of a one-rep max. Intensity can still be gauged using failure rates or proposed intensity scales for balance training and other less quantifiable interventions. The key is to avoid guessing and instead measure and adjust interventions to ensure they are achieving the highest possible therapeutic impact.

Research strongly supports the idea that higher intensities generally lead to better outcomes, provided they are safe for the patient. When therapists express concerns about the appropriateness of high intensity for their patient populations, the first question should be, "What intensity are you currently using?" If interventions are not being measured, there is no way to determine whether they are high, low, or somewhere between. Without this data, making informed decisions about adjustments or improvements is impossible.

In long-term care, the lack of equipment available in inpatient rehab can make precise dosing more challenging. However, simple tools can be highly effective. One approach I’ve used is providing therapists with a laminated modified Borg scale (1–10) and training them to gather subjective patient feedback. Asking patients how difficult they found an intervention allows for a starting point to gauge intensity. Aiming for moderate intensity is a good baseline, with high intensity being an option when possible. While this method has limitations, particularly with patients with cognitive impairments who cannot reliably use subjective scales, it is a meaningful step toward intentional dosing.

The gold standard would be a combination of subjective measures like RPE and objective measures such as heart rate percentages. While this requires more equipment and training, it represents the direction the profession needs to move in to demonstrate value and effectiveness. Generalized exercise without measurement or intentionality does little to differentiate skilled therapy from non-skilled activity. By prescribing interventions with clear goals and measurable parameters, we can maximize the therapeutic benefit and reinforce therapy's distinct value in achieving functional outcomes. This is not just about improving patient care—it’s about securing the profession’s place as a critical component of the healthcare system.

Example Groups

Here are a couple of examples of group sessions I commonly use, along with the thought processes behind them. These are designed to address functional goals while incorporating key principles we've discussed, like intensity, individualization, and multimodal engagement.

One of my favorite group sessions is a transfer group because it directly targets a functional goal many long-term care residents struggle with. Sit-to-stand exercises are particularly challenging physically, and they’re a fundamental component of transfers. Residents often need support in this area due to weakness or poor technique. A transfer group allows me to address these issues efficiently while tailoring the challenge for each participant. For instance, I might adjust the surface height, include or exclude the use of hands, or vary the movement speed. Anyone with a transfer-related goal is a candidate for this group.

I typically aim for moderate intensity for most participants in this group, as it’s a good baseline. For higher-functioning individuals, I might push for higher intensity. The modified Borg RPE scale works well in this setting because it’s simple, requires minimal setup, and correlates reasonably well with heart rate. I’ll have participants rate their perceived exertion and adjust the difficulty accordingly. If someone feels it’s too easy, I’ll make it harder to ensure we’re challenging them appropriately.

During the session, I provide individual cues on technique, like controlling the descent, reaching back to feel the surface before sitting or ensuring proper weight distribution. A great advantage of group therapy is using individual feedback to benefit the whole group. For example, if one participant demonstrates excellent technique, I’ll highlight that as a model for others. This shared feedback enhances the learning experience and reinforces good practices.

Another common group I use combines lower body strengthening with education, often targeting areas like discharge planning or fall prevention. Lower body strength, particularly extensor strength in the hips and knees, is a priority for many residents, especially those with mobility or fall-related goals. In these sessions, I alternate between rounds of resistance exercises and educational discussions during rest breaks. This approach maximizes the time spent and keeps participants physically and mentally engaged.

These sessions are particularly conducive to higher intensity since resistance exercises often feel safer for participants. They can be performed in controlled positions with minimal risk of falls or other injuries. I look for residents with lower body strength goals or a history of recent falls as candidates for this group. Discharge planning and fall prevention are common topics for the educational component since they apply broadly and involve considerations relevant to most residents.

Best practices for education in these settings include using written, verbal, and visual materials. The material should consider health literacy and be written at or below a sixth-grade reading level. For residents with mild or more advanced dementia, education is typically geared toward their caregivers. I often invite caregivers to participate in these groups, which enhances their understanding and ability to support the resident at home. This multimodal, inclusive approach ensures that education is effective and actionable.

These group models have been successful in my practice because they combine functional relevance, individualized intensity, and effective communication strategies. They also create opportunities for peer learning and caregiver involvement, which can enhance the overall impact of therapy.

Documentation 

The old adage holds true when documenting group therapy: if you don’t document it, it doesn’t happen. There’s an expectation to include more detail in group notes to justify the reasoning behind the choice of group therapy. While I haven’t encountered many denials specifically tied to group documentation, the requirement is clear: we must intentionally document and effectively capture the rationale for this method.

It’s essential to include a justification for the use of group therapy. Most therapy EMRs I’ve seen incorporate this requirement automatically. When you select the group code, the system typically prompts you to input why you chose group therapy and what specific benefits you expect it to provide for that individual patient.

Each individual session likely has several additional components of documentation that should be included by the letter of the law. This includes the specific benefits provided to the patient, the type of group conducted, what was performed, the duration of the session, and how it aligns with the patient’s goals. These details essentially justify the value of the intervention for the patient.

For example, a justification I often use highlights the value of visual feedback, socialization, and encouragement to participate—benefits that are genuinely applicable to most of my patients. Beyond these, there are other potential justifications, such as peer support, modeling, shared experiences, or simulating real-world activities. These elements often serve as valid reasons why group therapy is beneficial.

Clinically Managing Group and Concurrent, cont.

Staff buy-in has been one of the primary challenges since the transition to PDPM. Many clinicians were initially wary of group and concurrent therapy because they saw some facilities pushing it heavily, clearly tied to financial incentives. This skepticism often stemmed from a lack of prior experience with group therapy and a perception that it was being implemented solely for cost-saving purposes. If you’ve never done group therapy, seeing its potential benefits is hard.

However, as group therapy has become more widely practiced over the past five years, more clinicians are beginning to see the benefits. If staff buy-in is still an issue, it’s helpful to lean on the available literature and guidance from accrediting bodies about the impact of group and concurrent therapy. It’s important to remember that most research on multi-participant therapy, regardless of the setting, has shown it beneficial or neutral regarding patient experience and outcomes. To date, I haven’t seen any significant evidence suggesting a negative impact from group or concurrent therapy. This may change as research evolves, but the data currently supports its use.

When discussing staff concerns, I typically start by asking why they believe group therapy won’t benefit patients. Often, resistance stems from suspicion about financial motivations rather than concrete concerns about clinical outcomes. Engaging in these conversations and providing evidence-based support can help address skepticism and build confidence in group therapy’s value.

The physical demand of running group sessions is another significant barrier. While co-treat groups can alleviate some of the physical burden, co-treatment should only be justified when it provides clear value to the patient and aligns with their goals. Otherwise, it risks further reducing the patient’s overall therapy minutes, which is already a challenge under PDPM. When possible, leveraging support staff such as CNAs, activities directors, or aides to assist with setup, breakdown, or patient transport can help reduce the logistical challenges of group therapy. I’ve also had success coordinating with other departments and disciplines to ensure smoother transitions into group sessions.

Patient buy-in has also been a hurdle, especially in settings like upscale skilled nursing facilities, where patients are accustomed to one-on-one treatment. Initially, many patients felt that group therapy was a downgrade, associating it with a loss of personalized care. The key to overcoming this resistance has been proactive education. I start by explaining the benefits of group therapy during the initial evaluation. Framing group therapy as a valuable component of the plan of care sets the expectation early and allows patients to ask questions or express concerns.

In addition to education, highlighting the operational benefits can be helpful. For example, I often explain that participating in group sessions may allow us to allocate more overall therapy minutes across the plan of care. While patients can choose to stick to individual sessions, many appreciate knowing that group therapy can enhance their total time in therapy.

Practical strategies like scheduling groups at consistent times, inviting patients with specific goals to relevant sessions, and even providing written or verbal reminders can encourage participation. In some facilities, giving patients a printed “invitation” to group therapy sessions helps create a sense of inclusion and ensures they’re prepared to attend.

Ultimately, the success of group therapy hinges on clear communication, thoughtful planning, and ongoing education for staff and patients. Proactively addressing concerns and demonstrating the benefits of group therapy can help build trust and foster buy-in from all involved.

Strategic Implementation

Crafting group therapy sessions delivering the most value hinges on careful planning and aligning with functional goals. The key is to create groups that maximize outcomes by focusing on interventions with the biggest potential impact. Plan sessions intentionally, ensuring they align with patient needs and goals. Additionally, dosing is essential—not just for individual therapy but also for group sessions. Interventions should be delivered at an intensity level optimized for achieving the desired outcomes.

Setting clear expectations about group therapy from the outset is equally important. Communicate its benefits to both patients and staff early and consistently. Emphasize how group therapy can be an integral part of achieving therapy goals. Ensure that group sessions are scheduled with purpose, at times that minimize logistical challenges and maximize participation.

Documentation is another critical element. While it must meet regulatory standards and support audits, the aim should be efficiency. Documentation should provide enough information for another clinician to continue care seamlessly and withstand audit scrutiny. Beyond that, it doesn’t add direct value to the patient’s outcomes. In my view, the hierarchy of priorities should be to provide excellent clinical care first, ensure operational efficiency second, and meet documentation requirements third.

In reality, clinicians are often pulled in multiple directions—delivering quality care, maintaining efficiency, and meeting documentation standards. These demands compete for time and energy, and it’s difficult to excel in all three areas simultaneously. Quality care should always come first because it directly affects the patient. Efficiency is a close second, as it ensures the sustainability of services. Documentation, while essential, should not detract from the primary goal of delivering impactful therapy.

For group therapy documentation, focus on what is required—justify the rationale, demonstrate its connection to functional goals, and show that it requires a clinician's expertise. Anything beyond that might improve the presentation of the documentation but does little to enhance patient outcomes. Ultimately, the effort should go toward planning and delivering high-quality therapy sessions that make a meaningful patient difference.

Case Study

This case study highlights a very typical patient profile in long-term care—a 78-year-old male status post-fall with a right femur fracture, treated with a hemiarthroplasty. The challenges include pain, weakness, fatigue, and unsteadiness, all compounded by decreased tolerance for activity. The goals are standard: returning to independence in ADLs, mobility, transfers, and gait to facilitate a safe discharge home.

From the start, I would involve the patient in planning and setting expectations about the blend of individual and group therapy. I’d explain the noted benefits of group therapy, emphasize the 25% group therapy limit, and assure them that their care will still be heavily individualized. For many patients, hearing that group therapy can potentially increase the total minutes they receive often helps gain buy-in.

Next, I’d discuss the types of group sessions available and collaborate with the patient to identify those they are most interested in or likely to benefit from. I’d also delineate the interventions that require one-on-one attention versus those that can be effectively delivered in a group format. This patient's division is fairly straightforward: gait training, bed mobility, and high-level dynamic balance activities would remain one-on-one to ensure precise and focused intervention. Meanwhile, lower-body strengthening, transfer practice, and general activity tolerance could be addressed in group settings.

For example, a group focused on transfer techniques might include patients practicing sit-to-stand movements on varying surfaces, allowing individualized challenges within a group framework. Similarly, a lower-body strengthening group could incorporate resistance exercises tailored to each participant’s level while fostering socialization and encouragement.

While this case is relatively straightforward, lower-level patients present a unique challenge. Integrating them into a group may seem daunting if someone max assist for transfers. However, even positioning them in a supported chair and involving them in a basic exercise group can have surprising benefits. Seeing peers work through similar struggles with pain and fatigue often inspires these patients to engage more actively and develop a belief in their potential to improve. Although these patients are the hardest to incorporate, they frequently reap the most significant emotional and motivational benefits from group therapy.

Clustering patients with common goals or similar physical or cognitive abilities is a practical starting point for forming groups. That said, there’s also value in mixing abilities within a group. For example, pairing higher-functioning patients with those at lower levels can provide modeling opportunities for those struggling while giving higher-functioning participants a sense of leadership or encouragement. I’ve witnessed how mixing levels can spark unexpected improvements, even if it requires careful facilitation to ensure everyone benefits.

To manage this process effectively, we used to rely on whiteboards to track and organize groups by goals and abilities. While this is still a practical approach, I anticipate future tools, such as integrated EMR systems, will simplify this kind of clustering and planning. These tools could help us optimize group sessions, ensuring they meet clinical and operational goals while maximizing patient outcomes.

Group Considerations Takeaways

To effectively implement group therapy, you must balance planning and flexibility. While pre-planned sessions are invaluable for structure, efficiency, and collaboration with other departments, the unpredictable nature of day-to-day operations in healthcare requires you to remain adaptable. Factors such as patient conditions, facility operations, or sudden changes in availability may demand organic adjustments to your sessions.

Your approach must revolve around functional-based goals that directly address the specific needs of each participant. These goals ensure that sessions are meaningful and tied to measurable outcomes. During the session, your role as a facilitator is pivotal. You need to move from person to person, providing individualized feedback, adjusting intensity, and ensuring each participant is engaged and working at their maximum potential. This personalized attention within a group setting is key to achieving optimal results.

Preparation is another critical factor. Setting up the space and equipment to streamline the session can make all the difference in effectiveness and efficiency. Facilities vary widely in resources, but advocating for equipment that enhances your ability to deliver high-quality group therapy is worth pursuing. Leadership is often more likely to support the investment if you demonstrate that a particular tool or equipment improves outcomes or saves time.

Lastly, your documentation must meet the minimum standards we discussed, including the rationale for group therapy, the session details, and its connection to the patient’s goals. If you’re unsure whether your documentation meets these requirements, take the time to review and refine your approach. Comprehensive, clear, and concise documentation ensures compliance and reflects the high quality of care you provide. It’s essential for justifying your clinical decisions and for withstanding audits, ultimately supporting the credibility and success of your practice.

Projecting the Future of Group and Concurrent

Looking toward the future of group and concurrent therapy, it’s clear that healthcare is steadily shifting toward value-based care models, which prioritize outcomes and efficiency over service volume. While the current PDPM model is a step in the right direction compared to PPS, it doesn’t yet fully align reimbursement with patient outcomes. Programs like the Quality Reporting Program, Value-Based Purchasing, and facilities’ five-star ratings are starting to incorporate metrics like Section GG discharge function scores, but these are just initial steps.

Medicare’s goal to implement value-based care across all facilities by 2030 underscores the urgency of adapting to this shift. These models aim to reward facilities and providers for efficiency and effectiveness in achieving meaningful outcomes. In this context, group and concurrent therapy seem well-suited to meet the demands of value-based care by providing cost-effective interventions that maintain or even improve patient outcomes.

Beyond reimbursement, workforce shortages will also significantly shape the future of group and concurrent therapy. The aging population is increasing demand for long-term care services, but projections indicate there won’t be enough healthcare professionals, including nurses and therapists, to meet these needs. Group and concurrent therapy could be essential in addressing this gap by allowing therapists to see more patients while maintaining high-quality care.

Technology will likely be a driving force in overcoming logistical barriers and improving the feasibility of group and concurrent therapy. Emerging tools are expected to help streamline planning, scheduling, and executing these sessions, making them easier and more effective to implement. While it’s too early to say which technologies will prevail, it’s reasonable to anticipate a wave of innovation to optimize these models.

In summary, group and concurrent therapy are poised to become integral components of long-term care in value-based models. They align with the dual goals of efficiency and effectiveness, addressing financial pressures and workforce shortages. The next decade will likely expand the use of these models, supported by technological advancements and a growing emphasis on outcome-driven care. It’s an exciting, albeit challenging, time for clinicians to adapt and thrive in this evolving landscape.

Summary

Exam Poll

1)Which scenarios would be considered appropriate for concurrent therapy?

A. Two patients working on the same task under the supervision of two different therapists.

B. Two patients receiving individualized instruction from one therapist, each working on different tasks.   Correct Answer

C. A therapist providing treatment to one patient while another patient observes.

D. Multiple patients working independently on different exercises without therapist involvement.

2)What is the maximum number of patients that can participate in a group therapy session under Medicare Part A guidelines?

A. 2

B. 4

C. 6   Correct Answer

D. 8

3)What is the limit on group and concurrent therapy provision under PDPM?

A. 20 minutes per patient per day

B. 25% of minutes provided per patient day

C. 25% of minutes provided combined per discipline, per patient in a covered stay   Correct Answer

D. 200 Minutes provided combined per discipline, per patient in a covered stay

4)What is a consideration for determining the size of a therapy group?

A. Safety of all participants   Correct Answer

B. Age of participants

C. Height of all participants

D. Education level of all participants

5)Which of the following is a valid reason to avoid including a resident in a group or concurrent therapy session?

A. High prior level of function

B. Age

C. Isolation precautions   Correct Answer

D. They are a resident of a skilled nursing facility

Questions and Answers

Is treating a Med A patient concurrently with a Med B patient as part of a group therapy session allowed?

Yes, treating a Med A patient concurrently with a Med B patient in a group therapy session is allowed. However, it might not be financially advantageous. The group therapy code for Med B patients (97150) typically has minimal reimbursement, making it less beneficial from a financial perspective.

Has the definition of "group therapy" changed in recent years?

Yes, the definition of group therapy was updated in 2019 with the introduction of the Patient-Driven Payment Model (PDPM). The revised definition allows certain combinations, such as concurrent Med A and Med B treatments, but it requires careful consideration of reimbursement models.

Do you use group therapy for Med B patients?

Typically, group therapy is not used for Med B patients because the reimbursement model is not financially beneficial. However, in some cases where the clinical need justifies it, specific patients may be included in a group.

How is group therapy for Med B patients billed?

Group therapy for Med B patients is billed under the 97150 group therapy code. The minimal reimbursement associated with this code may discourage its use in some settings.

Why might some organizations discourage group therapy for Med B patients?

Organizations might discourage group therapy for Med B patients primarily due to poor reimbursement rates under the 97150 code. While it is allowed, the financial implications often guide these decisions, especially in a capitalist healthcare system.

Are there regional variations in reimbursement rules for group therapy?

Yes, regional variations can occur based on local coverage determinations set by Medicare Administrative Contractors (MACs). It is essential to check local guidelines to ensure compliance with specific reimbursement and billing rules.

What are your recommendations for increasing healthcare workers in rural areas?

A combination of strategies, including telehealth services, loan forgiveness programs, and federal incentives, could help increase healthcare workers in rural areas. However, telehealth remains a challenging business model, especially when facilitators are involved.

Is it beneficial to have structured, recurring group therapy sessions?

Yes, structured and recurring group therapy sessions are often the most effective. Regular scheduling allows therapists to refine their approach, improve logistics, and enhance the quality of care over time. Having one therapist consistently manage a group can lead to better long-term outcomes.

Does practice improve group therapy delivery?

Yes, therapists typically improve group therapy delivery with practice. Repeated exposure to the same tasks allows therapists to refine cues, equipment usage, and overall session effectiveness.

Any final advice on group therapy or reimbursement considerations?

Double-check local guidelines for reimbursement rules, as they can vary. Always balance clinical benefits with financial considerations to ensure sustainability. Structured planning and flexibility in group therapy are key to successful outcomes.

References

Please refer to the additional handout.