Time equals money and money equals time
SAID, CONTRACTED
All physical therapists in the for-profit organizations were contracted on an hourly basis. Any increase in physical therapist time had budgetary impact. The SUp research funded the physical therapists’ time and enabled physical therapists to prioritise SUp classes in their workload. In everyday practice, often group classes were cancelled or given to an assistant to take: “an exercise class is often the first thing to go off my list if I have lots of new referrals or someone very acute” (FAC#4). One physical therapist reflected on the possibility of continuing to provide SUp, saying “there’s no way they would be likely to allow me an hour out of my contracted hours… I couldn’t afford that much time. I would just get way too far behind on all my other stuff” (FAC#3). However, in the charity, physical therapy was available to all with the onsite physical therapy gym open to treat residents in the morning. In the afternoon physical therapists visited residents who “needed to be seen individually” (FAC#2). There appeared to be no cost sensitivity in the charity. The value the Board placed on physical therapy was reflected in physical therapists being employed on staff and well resourced. As such, the cost of physical therapy was already incurred “…we just know we fund physio…our team have just absorbed it” (Mgmt#5); this perhaps made it easier to make changes to physical therapist programs and for SUp to be maintained after the research program finished.To deliver SUp without additional funding in the for-profit organizations, management participants looked for workarounds that would mean the program was not delivered by physical therapists as designed and tested in the RCT. Even when value was seen, the cost was considered: “…I think there’s absolute value in it, it’s just about how we do it, what the workforce’s availability is and what the cost is to the sector” (SM#1). To this end, the management preference was to deliver SUp using diversional therapists or activity coordinators already employed so they wouldn’t have to pay for a physical therapist. When a physical therapist SUp facilitator asked a manager about SUp continuing: “…he [the manager] said yes to carrying on [SUp] but he thought that his activity coordinators were able to take over both sessions a week so he wouldn’t have to pay for a physio” (FAC#7). Another appeared resigned, saying “It is a bit of a pity but what I expected as they don’t like spending money on physio” (FAC#5). This led to not wanting to deliver the program with FAC#5 saying, “I don’t imagine [name] will pay for me to continue sadly as the classes literally double the hours I get there!”. Contracted physical therapists were acutely aware of their time costs and the impacts of funding. The contrast of contracting versus employing physical therapists to work in facilities demonstrated spending as little as possible to meet the requirements of the service agreement and create a profit versus not being profit driven. This highlights how business models and philosophies shaped care decision-making.