5 Strengths of a DON/DOR Team

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By JB Chua, DOR, PT, CEEAA, Summerfield Healthcare, Santa Rosa, CA

“If you play for the name in front of the jersey, then everybody will remember the name on the back.” — Sherwood Bassin

I did a book review with one of my employees this month, and we read The 5 Dysfunctions of a Team by Patrick Lencioni. After I finished the book, I reflected on these dysfunctions and how my relationship with my coworkers is, specifically with my Director of Nursing, Enedina De La Cruz. I am so proud to realize that we have overcome all these dysfunctions, and I would like to share the strengths (antonym of dysfunction) that we possess. Hopefully, it will serve as an inspiration to some of our partners.

  1. Presence of trust: Dina and I are not afraid to be vulnerable with each other. We are open to admitting our weaknesses as well as acknowledging our strong instincts in our unique characteristics as people as well as leaders.
  2. Acceptance of conflict: Conflicts are bound to happen between Nursing and Therapy teams. But instead of creating an artificial harmony by not addressing the problem and being satisfied with inferior decisions, Dina and I engage in a healthy debate where we listen to each other’s opinions to come up with the best possible solution to our facility’s problem.
  3. Unwavering commitment: When a decision is made after our debate, we know that we are both in, even when it may not have been the idea we had in mind. For us, it is not about who is right; it is about our opinion being heard and how we can do things right.
  4. Extreme accountability: From making sure that UDAs are being done, to what time the fall committee should happen, Dina and I make sure that we are holding ourselves accountable. We call each other out when we notice that something is getting dropped.
  5. Paramount attention to results: Whether we get good or bad results, we make it a point to make sure that we understand how we get there, how we can make it again or how we can be better. Dina and I understand that we are not just aiming for the success of the Nursing or Therapy department; we are aiming at a much bigger picture: the success of Summerfield Healthcare Center.

PDPM Lessons Learned - Section GG

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Submitted by Jennifer Raymond, Therapy Resource – Northern CA

During a recent NorCal Weekly DOR call, a question came up that prompted discussion regarding how Section GG scores are being determined when there is a discrepancy between Nursing and Therapy.

When we have differences between Nursing and Therapy scoring for GG, this must be reconciled per the RAI MDS manual criteria by answering the following question:

“What is the usual/baseline performance (days 1, 2, 3) BEFORE therapeutic interventions occurred?”

We cannot average or modify the assist levels that have been documented but instead through discussion and chart review need to determine which of those scores best represents the “usual/baseline performance” for this patient before the onset of any therapeutic intervention.

Therapy/MDS folks are clearly collaborating well to compare Nursing/Therapy documentation as part of the daily technical GG process. The next step is to ensure that when these values differ we are determining which documented assist level best describes the patients’ usual/baseline performance at the time of admission and discharge and are recording that score on the MDS.

Thank you NorCal DORs for bringing up this important topic.

Please reach out to your MDS/Therapy resources if you have additional questions and share this info with your Daily Technical Team!

Leaders Made Here - TJ Petty

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Submitted by Chad Long, Therapy Resource

For those of you who have never had a chance to meet Tyler “TJ” Petty, DOR at Montecito Post-Acute and Rehabilitation in Mesa, AZ…you should. TJ is a leader full of charisma, compassion and focused on moving his team and facility forward in a CAPLICO manner. He started his journey with Montecito in 2008 as a PRN Physical Therapist, then a full-time staff member in 2009 and has been the DOR since 2010.

Over the last 10 years, TJ has developed a dynamic therapy department in a very successful facility. Montecito has grown to an average census of 190 with 100 skilled patients. It is also a large Ventilator and Trach-dependent facility caring for acutely ill patients and fragile LTC residents, boasting 156 admissions and discharges per month!

I was able to ask TJ a few specific questions about his views on Leadership in order to gain a little insight into the success of Montecito:

How do you on-board and orient new therapy team members to a CAPLICO culture?

During interviews, TJ performs the first meeting on his own. Then the entire therapy team must interview the candidate and come to a unanimous decision to recommend the hire; “That new person will only be successful if we are all on board.” This process encourages healthy and vigorous debate among the team.

Next, the new team member’s first day on the job must be “memorable, in a good way.” Having the name badge and orientation paperwork ready, along with ensuring the mentor/trainer is prepared, is key to showing that Montecito therapy is proactive, professional and FUN. TJ loves to quote his former ED, Forrest Peterson, during orientation, “Our building will go as far as our therapy team takes us.” This sets the tone for the new member that therapy is looked to as leaders, ensuring the vision for the facility, so they should conduct themselves accordingly. “Once you get the ball rolling, the team will take over.”

Finally, TJ sits down with each new staff and discusses their personal/professional goals so he can facilitate the growth of that therapy leader.

What specifically do you do to grow leaders in your therapy department?

With such a large team and busy case load, TJ noticed the weekly therapy meeting was not focused and inefficient. Thus, he created his “rope teams.” Using the analogy from mountain climbing and how 3-4 members of a team are roped together and have different responsibilities, TJ linked teams of one licensed therapist to 2-3 assistants. The “Lead” therapists meet weekly with the assistants to discuss the patients, etc., AND THEN they also discuss anything else to build relationship and camaraderie. This is the rope team’s opportunity to build each other up, have fun and develop leadership skills.

Also, TJ meets one-on-one with his team, teaching them to bring problems with solutions and coaching them in their professional goals. From this process, TJ has helped grow two DORs and said, “Any therapist could take my job.”

How do you/your therapy team cross over and support other departments in your facility?

Each month the therapy department formally recognizes a CNA letting the individual and facility know how much therapy appreciates all the hard work and collaboration. Another example is having therapy take a teaching role with their nursing partners. Currently, therapy and nursing are learning the Ranchos Los Amigos Scale for their brain inured patients to coordinate therapy-nursing care effectively. The therapy staff also take IDT roles throughout the facility: Speech Therapy works closely with Respiratory to ween patients off the ventilator and progress them along in the trach process; Physical Therapy supports the Falls Committee, and each lead therapist is responsible for patient care conference; and TJ meets with nursing to identify LTC residents with mobility issues for the purpose of discharging them to a more independent level of care. “Who can we help get out of here.”

Also, every therapy staff member is ready to help support Marketing/Admissions with tours or supporting the facility in the community.

Who is a mentor to you and what specifically did/does that individual do that impacts your leadership today?

Three individual were immediately identified:

Forrest Peterson, former ED at Montecito and current Bandera Market Leader. TJ described, “seeing the way he would develop people and his thought process,” as very formative. Forrest would (still does) spend time with others, hold them accountable in a consistent process that TJ likened to the Mr. Myiagi approach of the 1980’s iconic movie, The Karate Kid.

His Father. “My Dad told me, once you get that job, make yourself as valuable as possible.” Thus, TJ makes sure he gets involved in every department, “whenever I can to figure out where I can help.”

Pat Tillman, football player with TJ’s beloved Arizona State University Sun Devils and professionally with the Arizona Cardinals, who enlisted with the U.S. Army after the attacks of September 11th. Pat Tillman was killed in April of 2004 in Afghanistan. “What a cool leader; he knew what was right for him and he did it, not for the recognition, but because he knew it was right.”

Thirst Quencher: The Free Water Protocol for Patients with Dysphagia

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By Elyse Matson, MA CCC-SLP, SLP Resource

The Free Water Protocol is one option SLPs may utilize to help counteract the adverse effects of thickened liquids and/or tube feedings. What is it? How should it be used in your facilities? What are the risks for aspiration pneumonia?

The (Frazier) Free Water Protocol was named after Frazier Hospital. In 1984, Frazier Hospital began to give all patients unlimited bedside water and/or ice chips. They found that fewer residents had UTIs and dehydration. They also found that when paired with proper positioning and oral care, there were no incidents of aspiration. Although it has been referred to as the “Frazier Water Protocol” in the past, the proper name is “The Free Water Protocol.” It is best used with patients on thickened liquids or patients who are NPO and on tube feeding.

The free water protocol is not appropriate for all patients. The below table can be used by the SLP to help determine the risk for pneumonia in each patient. As you might imagine, the higher the clinical complexity of the patient, the less likely a Free Water Protocol should be implemented. Remember that a patient on ice chips or free water has not been deemed free of aspiration on these textures; rather a determination is made that the benefits of free water outweigh the risk of pneumonia.

 

 

 

 

 

 

 

 

 

 

 

The Water Protocol is generally defined by these guidelines:

  • Patient is allowed to drink water between meals (minimum of 30 minutes after meals)
  • Water and ice chips cannot be provided during a meal if the resident is prescribed thickened liquids
  • The prescribed thickened liquid is provided at meals
  • Medication cannot be administered with water if resident is prescribed thickened liquids
  • NPO patients can have water anytime
  • Use all other swallowing guidelines
  • Must abide by other fluid restriction orders
  • Position upright always
  • No thin water until oral care is completed or 30 minutes after meal
  • Water is offered freely throughout the day

So what are the best methods to implement the Free Water Protocol? A multi-pronged approach is recommended.

First, a facility-wide training, including:

  • Patient identification methods
  • Facility-wide implementation as facility program not just a speech program
  • Provision of oral care to patients at risk for aspiration
  • Method for writing orders and care plan in PCC only after the oral care component is implemented
  • Communication methods with Dietary, Nursing, MD and family
  • Monitoring systems to assure the program is being followed
  • Communication about the specific methods for each particular patient, including:
  • Method for completing oral care
  • Licensed or nurse aid providing oral care (check your state laws for who can use oral suction)
  • If patient will receive unlimited or limited water or ice chips
  • Swallow strategies required for best safety
  • Documentation in place that states risks and benefits
  • Clarity on who will monitor proper administration of the protocol

In some facilities, especially when first implementing the Water Protocol, the clinical team may prefer a doctor’s order that does not refer to a protocol but rather an order that describes what a patient can and cannot have. “Patient may have Free Water Protocol” verses “Patient may have unlimited thin water via cup (no other liquids) between meals starting 30 minutes after meals and after oral care. Patient to be upright for all PO intake.”

The importance of oral care cannot be emphasized enough. Failures with a Free Water Protocol are almost always because the oral care component has not been fully implemented. Oral care in patients with severe dysphagia should be treated as a nursing treatment and may involve the use of oral suction and MD-ordered oral solutions such as chlorhexidine. If nursing has questions about the safest way to administer oral care in these patients, consult the SLP.

The benefits of the Water Protocol include:

  • Reducing risk for dehydration and the multiple sequelae from dehydration
  • Better adherence to other dietary restrictions
  • Decreased re-hospitalizations

If you are interested in implementing a Free Water Protocol and have questions, feel free to reach out to me at ematson@ensignservices.net.

DON/DOR/ED: “The Transformational Triad”

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Submitted by Jennifer Raymond, Therapy Resource, Northern CA

trans·for·ma·tion·al/tri·ad/ “able to produce a big change or improvement in a situation; “a group of three connected people or things

The objective of a triad is to create a peer-to-peer-to-peer relationship to accomplish a mutual purpose. “Triads are based on core values and mutual self-interest.”

A triad is not just three people meeting together. It is a relationship where each person is responsible for the quality of the relationship between the other. It is where each person has the other’s back. It’s “I’ve got your back and you’ve got mine” or “All for one and one for all.”

We have traditionally had one-on-one ED/DON relationships in the facilities as the leadership core. By adding that third person, the DOR, the power of the group is enhanced, the exchange of ideas and perception increased, it ensures faster and more accurate communication with the rest of the leadership/facility, it provides support and even friendship to the three members, it allows this core team to grow in their trust of one another, and it provides a place to be honest and safe when dealing with issues big and small.

Transformational Triad Opportunities to Achieve Amazing Things Together:

 

Achieving BHAG Nursing/Rehab team strengthening
CAPLICO/Culture training and events Long term care programming
Census development Managing managed care
Customer satisfaction Program development
Employee satisfaction and retention PDPM updates and planning
Decreasing readmission rates Productivity enhancement for therapy
Facility-wide dementia training QAPI
Facility staffing/Local recruiting Quality measures/QASP-*****
Identification of barriers to facility goal achievement Reasons to celebrate
Fiscal health and growth Relationship building within the community
Holding each other accountable Section GG and other MDS processes
Ensuring we meet Flag criteria Survey prep/follow-up
IDT leadership growth Support and friendship
Improving relationships with our hospital and managed partners “What If” intelligent risk taking brainstorming
Joint educational opportunities for Nsg/Rehab Worker’s comp management

 

“Three is the minimum number of legs required to make a stable structure.”

The Beauty of PDPM – What MIGHT Be There

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By Lori O’Hara, MA, CCC-SLP, PDPM Resource

One of the miraculous things about PDPM is that we are incentivized to go learn things! And … we have the patient with us, 24/7, sometimes for weeks! There is no other provider — not the acute, not home health, not outpatient, not anyone who gets to have their arms around the patients as closely as we do and who are also told to go learn absolutely as much as we can.

Just us, baby!

So this presents an incredible opportunity to be the best assessors, the best investigators and the best, most impactful providers a patient will come into contact with.

This means that we if work superficially — if we’re content with just the diagnoses on the transfer list and just the treatments that come to us — that we’ll miss out on the potential for incredible impact to a patient, which, super conveniently, is pretty reimbursable when we do it.

So part of being a PDPM Ninja is knowing where the arrows are pointing. What conditions tend to come in clusters? What treatments should we be advising the MD that we can do? What low-impact, non-invasive interventions could have a big payoff for this patient if we just think about doing them?

So here’s an exercise for you. Look at the diagnosis list below. And before you scroll down, think through all the “maybes.” What might related conditions be? What treatments should be considered? What condition might mask another where you should take a close second look?

So what did you find?

Here’s what I found:

        • Sepsis and Bacteremia = Need records to confirm or r/o septicemia
        • Diabetes and insulin = Check for diabetic retinopathy and proactive management of insulin regimen in case order changes are needed
        • Diarrhea = Investigate source (radiation, infection, c-diff?) to confirm or r/o inflammatory bowel disease
        • Convulsions and seizures = Investigate control status (25% of seizure disorders are poorly controlled/intractable)
        • Klebsiella PNA and sepsis = Query for labs for drug resistance status
        • Alzheimer’s disease and encephalopathy = Cognitive impairment
        • Obesity = Score BMI, assess if patient’s weight warrants morbid obesity diagnosis
        • PNA = Assess for need for RT interventions
        • UTI = Assess voiding and s/s of retention for straight cath medical management
        • Multiple malnutrition markers present (infections, dementia, diarrhea, dysphagia)
        • Dysphagia = Should trigger on Section K, which should then correlate to altered texture diet trigger for altered texture diet

Did you spot any others? You can also do this exercise with medical documentation from the upstream provider. And the more clinical brains, the better! Each clinician carries their own training and experience into the room, so one brain might pick up on something another brain might not spot. And when you find four or five “maybes,” you know that not every one of them will result in a new condition to code and care for. But you’ll probably find a thing or two, and maybe find something else — completely unrelated to payment — that will have a big impact on your patients’ health and recovery.

Like I said — miraculous!

 

What Makes a Good Leader?

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Submitted by Jennifer Sowers, DOR, McCall Rehabilitation, McCall, ID

I believe leadership is a position earned and appointed by those who have taken recognition of your ability to follow, listen, try harder to be a better person, think outside the box and be willing to learn.

Jocko Willink, a retired Navy Seal Commander, has written several books on leadership that are all worth the read if you want to be a better leader. Several truths to live by jump out in his books and podcasts, and the one that speaks loudly is: Discipline equals Freedom. What does this mean? First, why do we need discipline as a good leader?

In a leadership role, we are being watched. Our team is watching us; even those not on our immediate rehab team are watching us. The cooks, the CNAs, the Activity Director, not to mention our ED and the DNS. They are watching our attitude, our behavior, how we react in conflict or under pressure. Are we late for meetings? Do we roll our eyes? Did we yawn? How are we dressed? A full-time employee in our facility told me recently, “The rehab team is like the cool kids in high school — everyone wants to be like them and hang out with them.” At first it was a compliment, but then I started to think, why are we a separate “click” outside the big team? Do other employees think we are above reproach in the building? That’s when it really struck me how important it was that we as a team, and especially me as a leader, must demonstrate excellent leadership. We are in a spotlight. And we all know that with great power comes great responsibility, and as a leader, we are in a position of power.

And that is where ownership comes into play as a leader. If you make a mistake, don’t cover it up; admit mistake and then make a plan to do better. If your team makes a mistake, take ownership. When are we not responsible for the performance of our team? Never. If our team is not performing, then maybe they need more training, more assets, more support, more mentorship. Ask your team what they need and then follow up with them. That’s when a job will get done. Is the mission clear, concise and understood? Make sure professional expectations are clear and don’t compromise standards. As a leader, lead by example and take responsibility for your team. The other day a patient got extremely upset about a new RA not doing a specific exercise as she expected. The RA came to me, warning me this patient was mad and going to complain to me. I listened to the patient and then apologized to her, saying I had instructed the RA incorrectly and it was my fault she did not understand the specific exercise. The RA came to me later, smiling, and told me the patient had apologized to her and their relationship was restored. She was relieved and the patient was happy. If you make a mistake, own it. Don’t make excuses or cover it up. Neither the RA nor the patient were mad at me for not doing thorough training. It was amazing how quickly me taking ownership dissolved the conflict.

Leadership is all on you but it’s not all about you. The team is way more important than you are. Keep your team’s interests above your own, and use all the tactics you can to make your team better, not yourself. If your goal as a leader is to help others and your team, then you will accomplish the mission. If your team succeeds, then you win as a leader and your people will win. That is true leadership. But, it does start with you and that is where the truth that discipline equals freedom rings so true to the core of leadership. Here is a quote by Jocko Willink regarding the application of discipline:

Discipline starts with waking up early, it really does. But that is just the beginning; you absolutely have to apply it to things beyond waking up early. Is it working out, every day, making yourself stronger and faster and more flexible and healthier? Is it eating the right foods, to fueling your system correctly? Is it disciplining your emotions, so you can make good decisions? Is it about having the discipline to control your ego, so it doesn’t get out of hand and control you? Is it about treating people the way you want to be treated? Is it about doing the tasks you don’t want to do, but you know will help you?

Discipline is about facing your fears so you can conquer them. Discipline means taking the hard road, the uphill road. To do what is right. For you and for others. So often, the easy path calls us: to be weak for that moment. To give in to desire and short-term gratification.

Discipline will not allow that. Discipline calls for strength and fortitude and Will. It won’t accept weakness. It won’t tolerate a breakdown in will. Discipline can seem like your worst enemy. But in reality, it is your best friend. It will take care of you like nothing else can. And it will put you on the path to strength and health and intelligence and happiness. And more important, discipline will put you in the path to Freedom.

I think about freedom equaling discipline as a leader and a lot comes back to doing the right thing even when we don’t feel like it. Freedom for me is getting all my progress notes done on time, getting my discharges done on time so when I do closeout I don’t get a screen of red. Freedom is showing up for work early so I have good numbers to present at stand-up and my team has their schedules ready when they arrive. I have a running calendar, and the other day I flipped the page and it said, “I love running because it’s the one thing I do every day and never regret.” I’ve never said, gosh, I’m sure bummed I got up and ran this morning. Wish I hadn’t made my bed today. Or, I’m sure bummed I got all my notes done on time, or I’m sure disappointed I took a shower today, or ran my metrics, or did some continuing education. We’ve never said that. When we’ve had the discipline to go on the run, finish the progress note, pack a healthy lunch, we have freedom and we can lead our team to have the same freedom by example.

Lastly, a leader will never ask their team to do something they will not. As a leader, we need to care about our team. Advocate for your team, whether it’s new equipment, continuing education, time off, negotiating with nursing. Have their back and they will have yours. If your team knows you have their best interest in mind as their leader, you will have their respect. And, then when you need to give criticism, it will be accepted more easily. And celebrate! Set goals and celebrate with your team! Don’t forget to recognize victories and show them how much they are appreciated.

A lot goes into being a great leader, and these are just a few but they are the ones that have hit home with me lately. Take ownership, discipline equals freedom, lead by example, your team comes first, and show them you care.

Birds of Different Feathers

Building Therapy Leaders Learn

Improving Work Relationships

Are you objective, analytical, and logical? Are you a natural team player? Are you lively and entertaining? Are you a natural born leader? The answer to these questions and more may help you to better understand your work style, but more importantly, the work style of your coworkers.

We all have unique personalities and different learning styles. What you appreciate about your work may be different from what others appreciate about their work. What do you think a lot about, value in others, enjoy or dislike? What you have trouble dealing with may be unique to your work style. Knowing and understanding what makes you and your coworkers unique may better strengthen your relationships.

Recently at Premier Care Center, we began a distinctive training style to identify ourselves and our work style. We then share with our coworkers each other‘s work styles in an attempt to strengthen our work relationships. The therapy department took on a fun adventure to better understand our own traits and those of us on our team and how we may improve. We were introduced to a training course called “Birds of Different Feathers”. It is a quick Personal Work Style Self-Assessment. Once everyone has completed the assessment they use the score on the assessment to identify their own ‘Bird Style’. Once you know your bird, you may read the course information that identifies your unique characteristics. Knowing more about yourself is only half the fun. Once everyone shares their own unique ‘Bird Style’ with the group, then we were all able to discuss and learn about each other.

Some don’t like to be micro-managed. Some are natural ‘cheerleaders’ and thrive on the creative energy of groups. Some will respond well when they can be given autonomy and the opportunity to exercise their best professional judgment. Some prefer not to be criticized or embarrassed in front of other people. They are sensitive and care deeply what others think of them.

It was quite enlightening to learn about our teammates. We now use this ‘Bird Style’ terms when we speak to each other and it has given us deeper insight into how better to communicate together. We even presented the course to the Premier Care Center Leadership Team, and they have fully embraced it as well. More recently it was presented to the Ensign Therapy Resources as a culture training piece. So what kind of a bird are you?

Are you an Owl – a data collector? Are you a Dove – a collaborator? Are you a Peacock – an artist/creator? Are you a Hawk – a decision maker? Find out your own unique ‘Bird Style’ and how are you may better influence your communication with your team or coworkers by taking the training on ‘Birds of Different Feathers’.

So what kind of a bird are you?

Assessment: Personal Work Style Assessment (pdf file)
Training: Birds of Different Feathers (pdf file)

Be sure to take the assessment first, then the training.

Cupping Techniques to Improve Quality of Life for Geriatric Patients

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By Jimmy Dale Smith, PT, DPT, The Healthcare Resort of Plano, TX

Myofascial decompression (MFD), or cupping, is a form of IASTM (Instrument Aided Soft Tissue Manipulation), where a pump and a cup are used to create negative pressure and placed on the skin to improve circulation/blood flow, reduce pain, improve tissue pliability/mobility and to improve healing.

Additional benefits of cupping may include improved quality/quantity or ROM, improved tolerance to ROM/PROM exercises, and excellent neural input to improve motor output. Contraindications include open wounds, fever/active infection, severe disease (cardiac, renal failure, bleeding disorder, hemophilia, active cancer and dermatitis), first trimester of pregnancy, unhealed or possible fracture, severe strain/sprain, or already inflamed/swollen tissue, burns and acute flare-ups of skin disease (psoriasis, eczema or rosacea).

  • When: Depends; early in POC to assess patient’s response
  • Where: Location of pain/perceived stiffness, myofascial line, neurovascular junction
  • Why: ROM, pain, blood flow, soft tissue adhesions
  • Who: Patients who do not have contraindications
  • What: Reassess, test and retest

Pilot Study: Plano Health Care Resort

The Physical Therapy department at Plano HCR is currently one of our affiliates in Keystone that is piloting usage of cupping across patients with differing diagnoses, which has resulted thus far in varying degrees of success. Predominantly, the facility has observed a positive response to MFD. Through the observations, benefits range from an hour (to the end of the session) up to five to seven days of pain relief. One specific “home run” of treatments is the following case study.

Case Study: Mr. T.

Mr. T. is a mid-70s male s/p R TKA. He presented to PT as an outpatient seeking further rehab after his SNF stay. His primary limiting impairments were stiffness, pain and weakness. When he initially attempted basic OKC (open kinetic chain) activities, the patient would report moderate to severe pain at end-range knee extension. The team attempted to modify to a CKC (closed kinetic chain) to assess differences in symptoms. Stiffness remained. Moving to manual therapy, the patient responded decently well with anterior tibiofemoral mobilizations. The patient reported less pain, but the stiffness remained. The PT team applied three hard plastic cups with 1.5 pumps of pressure proximal to the knee as a gross stabilization point for the fascial system and one silicone cup just distal to those cups with the intent to perform a dynamic mobilization technique. Post-treatment, the patient reported that not only was the pain nearly eliminated, but the stiffness was gone as well.

SLPs’ Role in Discharge to Home/Community

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By Tamala Sammons, MA CCC-SLP, Senior Therapy Resource

Contributed from the American Speech and Hearing Association (ASHA.org) https://www.asha.org/practice/reimbursement/medicare/medicare-patient-driven-payment-model/#Fall

SLPs can help increase the rate of discharge back to the community and decrease avoidable rehospitalizations. Specifically, SLPs can positively influence the following factors that contribute to discharge back into the community:

Communication: A primary purpose for addressing communication and related disorders is to affect positive measurable and functional change(s) in a person’s communication status so that they may participate in all aspects of life — social, educational and vocational.

Communication is central to discharge back into the community, especially in individuals with speech/language impairments or cognitive deficits associated with a variety of diagnoses. Several studies have indicated that communicative competence predicts individuals’ safe discharge back to the community.

  • For example, a 2013 study found that deficits in auditory and reading comprehension and oral spelling to dictation were significantly associated with increased odds of discharge to a health care facility (e.g., SNF), rather than to a community-based environment, after adjustment for physical therapy and occupational therapy recommendations (González-Fernández, et al., 2013).
  • Functional dependence and comorbidities, such as chronic aphasia, have been found to be a significant predictor of a non-home-based discharge setting in post-stroke individuals (Mees, et al., 2016).

The SLP’s scope of practice and unique training specifically equips them to prepare individuals to return home with appropriate communication facilitators, as needed, ensuring maximum safety.

Cognition: Cognition is an important predictor of safety and functional independence in determining discharge to home, even in individuals undergoing purely orthopedic-related rehabilitation (Ruchinskas, et al., 2000).

Several studies emphasize the importance of cognition in the ability to return to completely independent living after medical rehabilitation in geriatric patients (MacNeill, et al., 1997). The Scope of Practice in Speech-Language Pathology (ASHA, 2016), as it relates to cognitive-communication impairments, indicates that the practice of speech-language pathology includes providing prevention, screening, consultation, assessment and diagnosis, treatment, intervention, management, counseling, and follow-up for disorders of cognitive aspects of communication (e.g., attention, memory, problem solving, executive functions).

Swallowing: SLPs with appropriate training and competence diagnose and manage oral and pharyngeal dysphagia. SLPs also recognize causes, signs and symptoms of esophageal dysphagia and make appropriate referrals for diagnosis and management. Presence of dysphagia represents a significant barrier to returning home, specifically in neurogenic diagnoses. Those individuals with dysphagia, post-stroke, are more likely to be discharged to institutional settings, such as SNFs, after inpatient stroke rehabilitation, and experience longer stays at these facilities (Nguyen, et al., 2015). Aside from the significant costs resulting from chronic dysphagia and associated care, these conditions have a negative impact on an individual’s quality of life.

Health Literacy: More than just a measurement of reading skills, health literacy also includes writing, listening, speaking, arithmetic and conceptual knowledge.

According to the IOM report (2004), health literacy is “the degree to which individuals have the capacity to obtain, process and understand basic information and services needed to make appropriate decisions regarding their health.” Inadequate health care literacy affects all population segments but is predictably more common in certain demographic groups such as the elderly.

Patients with aphasia or other neurological disorders affecting speech, language or cognition, or those with severe hearing loss, are at risk when presented with vitally important written or verbal medical information. In addition, patients who face the stress of a medical crisis, possibly without an advocate or a significant other being present, or while in a state of pain, confusion or depression, may have difficulty understanding written or verbal medical information.

SLPs have a vital role in effective patient-provider communication. As federal laws, regulations, guidelines and accreditation standards mandate improved patient provider communication, it is vital to maximize the SLP’s contributions to this significant area of practice that impacts patients’ safe discharge back to the community. The rate of hospitalization and use of emergency services is higher among patients with limited health literacy (Kindig, et al., 2004). SLPs can assist with discharge planning while considering an individual’s health literacy to minimize these costs (Rasu, et al., 2015).