Evolving Roles for SLPs: Surviving and

Thriving in a Transforming Health Care

Environment
Becky Cornett, Charlette Green, Ann Kummer, Nancy Swigert,
Molly Thompson

1
 Disclosures:
• Non-financial: Each presenter served on the ad hoc committee for Reframing the
Professions. Much of this content is drawn from the final report.
• Becky Cornett – No financial disclosures
• Charlette Green – No financial disclosures
• Ann Kummer – No financial disclosures
• Nancy Swigert – No financial disclosures
• Molly Thompson – No financial disclosures

2
 Topics:
• Healthcare payment trends (Becky) Nancy subbing for Becky
• How this impacts SLPs in education settings (Charlette)
• Using outcomes data to inform practice decisions (Nancy)
• Focusing on function in goal writing and service delivery (Charlette)
• Looking beyond “typical” roles of the SLP (Nancy)
• Working at top of license/shifting responsibility (Ann)
• Streamlining documentation (Molly)
3
ASHA ad hoc Committee on Reframing the
Professions
• Final report submitted December
2013
• Available at:
http://www.asha.org/uploadedFile
s/Reframing-the-Professions-
Report.pdf#search=%22reframing
%22

4
Payment Trends in Health Care:
Update on the Journey to Value
Becky Cornett

5
 Who is driving the change?
• Purchasers
• Employers
• Government payers
• Individuals
• Asking health care providers to focus on improving health status of the
patient
• NOT focusing on discrete visits, procedures, surgeries that are not coordinated , are of
inconsistent quality and do not consider cost incurred by all stakeholders

6
 Providers are asked to be accountable by
assuming risk
• Performance: by meeting quality indicators
• Utilization: moving high cost acute care to other venues
• Financial: accepting payment to cover all services within a certain time period

7
The Journey from Volume to Value: Outcomes
that Matter to Patients are the Bottom Line
“A Tectonic Shift is happening in health care, where outcomes are
the bottom line and where the system conforms to the patient,
rather than the patient conforming to the system” – Optum Health

8
 Goals of Health Care Reform
• Improve quality & experience of care for individual patients; improve health
status of populations; contain costs.

9
 IOM’s Definition of Quality: It’s all about
achieving outcomes (results)
• Quality: the degree to which health services for individuals and
populations increases the likelihood of desired health outcomes and
are consistent with professional knowledge
• Health outcomes and payment in the future will be commensurate with results achieved
relative to the costs incurred by health care purchasers.

Source: Institute of Medicine

10
The Value Question: What results are we
getting for our money?

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Critical importance of measuring and achieving
value for all stakeholders
• Measuring the value of health care requires us to integrate clinical and
financial performance; focusing on the total costs and resource use
associated with the outcomes providers and persons served achieve together.
• Achieving high value for patients must become the over-arching goal
of health care delivery. If value improves patients, payers, providers and
suppliers can all benefit while the economic sustainability of the health care
system increases.

Source: Michael Porter, Ph.D., Institute for Strategy & Competitiveness, Harvard Business School
http://www.isc.hbs.edu/Pages/default.aspx

• Pointed concerns about the economic sustainability of the health care system – especially
relative to questions about the mediocre health status of much of the population –has 12
brought us to this juncture
•
Payment Changes Prompting the Evolution of
Clinical Practice & Journey to Value
• Since 1999 reports published on high rates of errors in hospitals & poor
health status in U.S. compared to other nations – despite spending more on
health care than any other nation.
• Effectiveness questioned – Americans receive only 55% of indicated care – yet
overuse and misuse of care rampant.
• Care inefficiencies – 30% of spending attributed to waste.
• Care disparities/inequities evident - based on race, ethnicity, socio-
demographics.
13
 Fee-for-Service(FFS) system under fire:
providers focus on volumes of services, not
value
• FFS system encourages more services and more expensive
procedures.
• Care is largely transactional, not coordinated.
• Wide variation in treatment patterns – not based on evidence but
on individual practitioner preferences.
• No assurance of quality – payment not tied to safety, efficiency, or
results.
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 The Journey from FFS Payment to Provider
Risk Models
• Both government and commercial payers are moving rapidly to encourage
providers to accept performance risk (quality indicators; outcomes
measures) and financial risk (responsible for costs and results of care within
defined parameters- which may range from a payment bundle for a patient
condition such as “stroke” to per-member-per-month payments for ALL
care needed for an “enrolled life”).
• The trajectory of change depends on many factors, including regional and
local market forces.
15
The Hierarchy of Financial Risk to Providers

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Source: AthenaHealth Knowledge Hub ©2014
Payment Model Hierarchy based on provider
performance and financial risk

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 The Transition from Volume to Value

• Value-based payment is expected to overtake traditional fee-for-

service by 2020, with 2/3 of payments involving provider risk
contracting.
• The majority of payers are already using some form of value-
measurement (value-based purchasing or “pay for performance”
which offers incentives for meeting certain metrics).

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 Medicare’s Value-Based Purchasing Program

• The Hospital VBP Program rewards (or penalizes) hospitals based on quality
metrics. CMS withholds part of the annual payment update - hospitals can
earn back the withheld amount by meeting goals re: processes of care,
morality, readmission rates, patient experience of care, hospital-acquired
infections.
• There is also a hospital outpatient VBP program as well as one for IRFs,
SNFs, and Home Care].

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 Current VBP-Related Programs For SLPs

Claims-Based Outcomes Reporting

http://www.asha.org/Practice/reimbursement/medicare/Claims-Based-Outcomes-Reporting-for-
Medicare-Part-B/

PQRS: (for SLPs in private or group practices)

http://www.asha.org/News/2014/Medicare-Releases-2013-PQRS-Participation/
http://leader.pubs.asha.org/article.aspx?articleid=1854288

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 Next in the Hierarchy of Risk: Bundled
Payments for Episodes of Care
• Bundled or episodes of care models provide a single negotiated payment for all the
services needed for a specified procedure or condition (e.g. joint replacement, stroke,
COPD, AMI) over a specified time period (30, 60, or 90 days typically).
• Over 500 hospitals and providers have enrolled in CMS’ Bundled Payment
for Care Improvement program to date; more than 6,000 hospitals,
physician group practices and post-acute care providers have applied to
participate CMS’ Bundled Payment for Care Improvement (BPCI) program
in 2015.
21
 Bundled payments, continued

• Most bundled payment contracts to date – governmental or

commercial – are retrospective: participants bill FFS claims as
usual, but a reconciliation process determines the final
payments for the episode, comparing the aggregate amount to the
pre-established discounted bundled price to be paid.

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Depiction of Traditional FFS vs. Bundled
Payments

Communication and
collaboration are key. No
one wants to be the
provider who adds cost

23

Source: Stryker Performance Solutions. Bundled Payments. © 2014

 What about “Accountable Care” and ACOs?

• Accountable care refers broadly to organizing and delivering

health care services focused on achieving superior health
outcomes while demonstrating a high degree of
stewardship of financial, human, and material resources.
• “Accountable care” is the responsibility of all, not limited
to an Accountable Care Organization (ACO).....
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 What is an ACO?
• An ACO is a coordinated system of providers who are
responsible for all of the health care and related expenditures for
a defined (attributed or enrolled) population.
• An ACO may operate under a variety of payment models simultaneously
according to contract terms.
• There are 600 + ACOs nationwide.

25
 ACOs, continued.

• To be successful, ACO providers must operate as a high-performance

network that is aligned, patient-centered, collaborative, and
accountable for results.
• Providers integrate the clinical and financial aspects of care,
reporting externally on the outcomes and costs of care –
continuously reviewing data to improve results- for patients and
for the organization. Robust data analytics is critical to success.
26
Example of an ACO Model – the ACO does
not need to own all components

27
Source: clinical-innovation.com
 Capitated Payment Models

• Full risk capitation means that providers are responsible for all
services (hospitalization, ancillary services, procedures, tests) and
costs associated with the health of a population under contract
often paid via PMPM – “per member, per month” payments.
• Partial capitation involves a single monthly fee for a defined set
of services associated with sub-sets of clinicians and/or patient
conditions.
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 An Era of Mixed Payment
and Service Delivery Models
• It is likely that provider organizations will be involved in some or
all of the value-based payment models over the next few years.
• Meanwhile, new provider-payer arrangements are emerging:
payers who own clinics and hospitals; hospitals that own health
plans; and providers who contract directly with self-insured
employers.

29
 Also: The Growth of Retail Care
• Consumers are footing more of the bill for their own care (the trend is
toward high-deductible health plans with co-pays and co-insurance).
• Consumers are price-sensitive, and focused on results that matter to their
everyday lives.
• A number of providers, including SLPs, are offering out-of-pocket options
including on-line care by subscription, apps, and other programs in lieu of
traditional insurance-based office care.

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 Key Competencies for Providers:
The Next Era of Healthcare
• Integration and alignment among providers across the care continuum -
make best practices standard.
• Ability to manage risk – determine and stratify patient risk of high-cost care;
target interventions to the facilitators and barriers to participation in daily life
activities; consider the multiple determinants of health status.

31
 Key competencies, continued
• Demonstrate facility with clinical, programmatic, and financial data analytics.
• Determine costs of care and resource use for identified populations in order
to contract successfully.
• Demonstrate a “propensity toward value:” willingness to redesign clinical
and business models to achieve results; incorporate outcome measurement
into everyday practice.
Source: Health Care Financial Mgmt. Assoc. (HFMA)
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 How changes in health care
environment impact SLPs in education
settings
Charlette Green

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 Reauthorization of Elementary
and Secondary Education Act
• SLPs in the public education setting may find this similar to NCLB of 2001
• NCLB Is Based on Four Principles of Educational Reform
1. Stronger accountability for results;
2. Increased flexibility and local control;
3. Expanded options for parents and
4. An emphasis on teaching qualifications and methods. Of these four, accountability
for results is the principle that has the potential to greatly improve the educational
results for children with LD.
34
 IDEA 2004: Improvement Act
• Special education and related services should be designed to meet unique
learning needs of eligible children with disabilities.
• Students with disabilities should be prepared for further education,
employment and independent living

35
 Impact on SLPs in Public Education
• Focus shifted from medical model to an educational model
• Focus on services in the general education classroom
• Focus on generalization outside of the speech room
• Focus on curriculum-based therapy

36
 Impact on SLPs in Public Education
• SLPs working on educational interdisciplinary teams focusing on educating
the whole child
• Focus on evidenced-based practice and accountability
• Shift from sole person responsible to becoming a facilitator of improved
communication

37
Using outcomes data to inform
practice decisions
Nancy Swigert

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 Measuring functional change:
Outcomes data
• Describe change in a way that is meaningful to others
• A change in applied aspect of a skill
• Individual able to eat an entire meal in reasonable period of time due to….increased
tongue strength
• Individual able to converse with friends over lunch due to …improved receptive and
expressive language skills.

39
 Patient-centered outcomes research
• Patient-Centered Outcomes Research Institute (PCORI)
• Independent, nonprofit entity with public and private funding
• AHRQ and NIH Directors serve on PCORI’s board and methodology
committee
• Sets priorities and coordinates with existing agencies that support patient-
centered outcomes research

40
 The power of data

 Analyze and improve the way SLPs

provide services
 Provide answers for clients and their
families about expected outcome
 Provide information to
administrators/third party payers
about the value of SLP services
 Benchmark performance against
system and national data
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 Outcomes data can be used to:
• Establish baseline status
• Determine effectiveness of interventions
• Inform patients of progress in a quantifiable manner
• Inform payers of progress to enhance reimbursement
• Provide data over time to improve care

42
 Questions data can answer
 On average, how many sessions are
needed to treat an adult with aphasia
or dysphagia?
 On average, how much gain will a
patient demonstrate during a given
time period within a specific
treatment setting?
 How many sessions will it usually
take to get a patient off tube
feeding?
 Do patients progress faster with
more intensive treatment?

43
 ASHA NOMS
• ASHA National Outcomes Measurement System (NOMS) Functional
Communication Measures (FCMs)
• Multidimensional tool – measures supervision level required and diet level
• 1998 -2012
• 102,541 patients in data base scored on the FCM for swallowing across all settings
• 59,502 scored on swallowing only
• 43,039 scored on swallowing + other FCMs

44
 Reporting Functional Status
• Outcome measurements scales – FCMs
• Disorder specific 7-point scales
• Ranging from least functional level 1 to most functional level 7
• Describes change in functional communication and swallowing over time
• Selected based on individual treatment plan
• Not dependent upon any formal assessments

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 NOMS- Adult
Functional Communication Measures
AAC                                  Alaryngeal Communication
Attention                        Fluency   
Memory                         Motor Speech
Pragmatics                     Problem Solving
Reading                          Spoken Language Comprehension
Swallowing                    Spoken Language Expression
Voice                              Writing

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 Data collected at two points of care
• Beginning of treatment • End of treatment
• Demographics • Service delivery
• Diagnostics • Functional status
• Functional status

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Patient characteristics
Age

Race
ethnicity

Gender
Patient characteristics

Medical
diagnosis

SLP
diagnosis

48
 Service delivery characteristics
• Current treatment setting
• Setting prior to admission
• Previous SLP treatment
• Frequency/intensity of services
• Post treatment setting

49
 Examples of tools for assessing functional
swallowing skills
• Functional Outcome Assessment of Swallowing (WSHA, 1996)
• Functional Outcome Swallowing Scale (Salassa, 1997)
• ASHA National Outcome Measurement System – Functional
Communication Measures* (1998)
• Functional Oral Intake Scale (Crary et al 2005)

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 Swallowing FCM synopsis
• Level 1: NPO with tube feeding
• Levels 2-4: Tube fed, but may take some PO
• Level 5: All nutrition/hydration by mouth with minimal restrictions
• Levels 6 & 7: Eats independently, some cueing or compensatory strategies

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 Moving from NPO to some PO
Patients scored on Swallow FCM only

Setting N=Level 1 at admit % Level 5 or higher at discharge

from that setting
Acute care hospital 4,951 27.3%
Inpatient Rehab 4,573 33.2%
Skilled nursing facility 1,604 16.7%
Outpatient settings 460 31.7%

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Moving from full or partial tube feeding to full
oral feeding
Setting N=Level s 1-4 at admit % Level 5 or higher at
discharge from that setting
Acute care hospital 13,834 35.6%
Inpatient rehab 9,470 41.8%
Skilled nursing facility 20,291 38.9%
Outpatient settings 1,975 58.5%

Percentages similar for patients scored on Swallowing FCM + other FCMs

N is higher.
Presumably those are patients with more impairments (e.g. accompanying language 53
disorders )
FCM Start Score for Dysphagia Patients at Admission to
Acute Inpatient Care

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FCM Score for Dysphagia Patients at Conclusion of SLP
Treatment in Acute Inpatient Care

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FCM Start Score for Dysphagia Patients at Admission to
Inpatient Rehab

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FCM Score for Dysphagia Patients at Conclusion of SLP
Treatment in Inpatient Rehab

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Proportion of patients on feeding tubes at admission who received all
nutritional intake by mouth at discharge, by treatment setting

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 Patient-reported outcomes
• Patient reported outcomes (PRO) have been defined as "any report of the 
status of a patient's health condition that comes directly from the patient, 
without interpretation of the patient's response by a clinician or anyone 
else." (FDA 2010) 
• PRO tools measure what patients are able to do and how they feel by 
asking questions.
• These tools enable assessment of patient–reported health status for 
physical, mental, and social well–being.

59
 Patient-Reported Outcomes Measurement
System (PROMIS)

• PROMIS (funded by NIH): A system of tools that measure patient-reported

health status, including symptoms, function, and well-being
• Use of PROMIS data:
• Evaluation of effectiveness of interventions for various conditions
• Research in chronic health conditions

60
 NIH's Patient Reported Outcomes
Measurement Information System (PROMIS).
• “While PROMIS and other initiatives have validated patient-level outcome
measures and instruments, there are two major challenges to using them for
purposes of accountability and performance improvement:
• They are not in widespread use in clinical practice.
• Little is known about aggregating these patient-level outcomes for measuring
performance of the healthcare entity delivering care.” (Pace, n.d.)

61
 Several examples of PROs in dysphagia
• SWAL-QOL
• SWAL-CARE
• MDADI
• EAT 10

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 SLPs: Seize the Opportunity to “Showcase” Critical
Importance of Functional Status

• Use the ICF Framework with care teams to structure care to achieve
outcomes that matter to patients’ everyday lives:

63
Outcomes that Matter and the ICF Framework

• The ICF framework enables an holistic approach, moving away from

incremental improvements in impairments – test scores and % accuracy on
discrete tasks; to a focus on all the factors that matter to patients’ ability to
participate in the many contexts of life.
• ASHA is forming an Ad Hoc Committee on the ICF charged with
applying the ICF framework to goal-setting and outcomes
measurement.

64
Focusing on function in goal writing
and service delivery
Charlette Green

65
 Functional Goals
This
• Focusing on what is important to the
student/patient/client first
• Information from assessments inform
mastery criteria but are not the sole
source of goals.
• Focus is on the real world and is
multidimensional!
Not This
• Focusing on arbitrary goals
determined by the SLP alone
• Goals are derived from therapist-
given tests alone.
• Focus is one dimensional!
66
 Service Delivery

This Not This

• Address goals using materials and
in the environment where the
student/patient/client will be
responsible for using them.
• Focus is on generalization!
• Address goals with un-meaningful
materials in separate settings
without concern for carry-over or
generalization.
• Focus on skill-drill in the separate
setting.
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 Anticipated End Result: The
Student/Patient/Client is:
• More involved in the evaluation process
• More involved in determining the goals and mastery criteria
• Therapy is more meaningful because it is patient focused/centered
• Therapy materials use real world, meaningful materials
• Therapy setting is as close to the natural setting as possible and plans for
generalization from the first session
• Patient has more accountability for the outcome vs the SLP fixing the patient!
68
Looking beyond “typical” roles of
the SLP
Nancy Swigert

69
 Moving beyond “typical roles”
• Understand what your facility is trying to do to survive in the new health care
arena
• Requires you to understand things like:
• Reimbursement methodologies
• Value-based purchasing
• Pay for performance

70
 Remember the triple aim
• Improving the patient experience of care (including quality and satisfaction)
• Improving the health of populations
• Reducing the per capita cost of health care

71
How can the SLP help the facility achieve these
goals?
• As facilities move away from department-specific productivity goals based on
direct service to patients, SLPs will have the opportunity to demonstrate
their value to the facility/system in other ways

72
 Example: Reducing readmissions
• Hospitals are penalized financially if patients are readmitted within 30 days
of discharge
• One of the target populations is patients with pneumonia
• The SLP can have a role analyzing re-admissions and working with the re-admissions
team to reduce re-admissions
• Dysphagia screening for any patient with pneumonia?

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 Example: Improving patient experience by
using more effective teaching methods
• SLPs are experts at communication
• They could be the resource at their facility for teaching other staff how to
effectively convey information to patients
• Teach-Back
• Ask Me 3
• SLPs can detect subtle comprehension deficits in patients to determine they
are not understanding discharge instructions

74
 Example: Poor health literacy costs the health
care system $$
• The SLP could lead the effort at the facility to address health literacy
• Training other staff in what health literacy is
• Helping develop teaching materials and methods to utilize with patients who have
varying degrees of health literacy

75
 Example: SLPs as case managers
• In order to keep patients in their homes and out of more expensive care
settings, case managers/coaches are being utilized
• Call the patient after discharge
• Help arrange follow-up MD visits
• Pick up meds and organize them
• Could SLPs be the case managers for patients with communication
disorders?

76
 Example: SLPs as coaches for parents of
toddlers
• Instead of seeing only children with defined delays in development, SLPs
could instead coach parents of any young child in speech-language
development
• Helping parents develop skills to help prevent deficits

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 Disruptive technologies
• Be prepared for a time when technology takes the place of something SLPs
do--- what if ?
• Apps on I-pad could improve receptive language as well as 1:1 therapy
• Digital screening device for dysphagia eliminates need for clinical swallow exams
• Medication advances eliminate Parkinson’s, Dementia
• Computer-based program can diagnose school-age language disorders
• An implantable device eliminates pharyngeal dysphagia
• Tele-health becomes the standard method of providing services
78
Working at top of license/shifting
responsibility
Ann Kummer

79
 Top of License
(AKA Leveraging)
• HC providers should ONLY spend time doing things that require their
professional skills and training
• HC providers should NOT spend time doing things that can be done by
those who are less skilled and lower paid

80
 Top of License

• For MDs, expanded services can be provided by:

• Nurse practitioners
• Physician assistants
• Pharmacists
• Social workers
• Administrative staff

81
Top of License

82
 Top of License

• More cost-effect to have lower paid, less skilled people (i.e.,

support staff) to support services
• HC provider can see more patients (increase access), and generate
more revenue

83
 Top of License
When professional people work at the top of their license…
• Win for the professionals
• Win for the patients
• Win for the business
 Top of License for SLPs
• SLPs should provide only those services that require a level of complexity
and sophistication that only an SLP can perform.

85
 Top of License for SLPs:
Admin Support
• Administrative support
• Paid support staff
• Students
• Volunteers

86
 Top of License for SLPs:
Admin Support
Dedicated support staff should do all of the following:
• Scheduling
• Insurance auths
• Phone calls
• Mailing of letters, reports, etc.

87
 Top of License for SLPs:
Admin Support
Pre-visit planning by support staff:
• Pre-evaluation questionnaire (paper, online, or on phone)
• Pre-visit parent interview
• Use of self-management questions when making appointments to
ensure commitment and attendance

88
 Top of License for SLPs:
Admin Support
• What if you can’t afford to hire support staff ?
• Actually, you can’t afford NOT to hire support staff.

89
 Top of License for SLPs:
Admin Support
Cost per hour when SLP schedules: ($33.65)

Revenue per hour when a support person schedules and the SLP treats a patient:
Revenue from charges: $200.00
Cost for SLP: ($33.65)
Cost for support staff: ($15.00)
Profit $151.35/ per hour
90
 Activity: Cost of Wasted Time

• One cherry tomato…

• One hour per week…

91
 Question at the ASHA Business Institute: 2013
What would an SLP prefer to do? 98%

1. Schedule a patient
2. Obtain insurance authorization
3. Produce a diagnostic report
4. Treat a patient

0% 0% 2%

1 2 3 4
 Top of License for SLPs:
Admin Support
SLPs should not do administrative tasks
• SLPs are happier doing clinical work
• SLPs are not that good at admin tasks
• SLPs time = access and money

93
 Top of License for SLPs:
Clinical Support
• Clinical support
• SLP assistants
• Students
• Volunteers
• Parents/family members
94
 Top of License for SLPs:
Clinical Support
To increase your support and decrease your costs:
• Develop a Student Volunteer Program

95
 Top of License for SLPs:
Clinical Support
Use students to: • Make communication boards,
• Set up and clean up handouts, etc.
• Organize materials and • Take a history over the phone
cabinets • Do literature reviews
• Make copies • Do crafts for use in therapy
• Run errands
• Call families
96
 Top of License for SLPs:
Clinical Support
Student Volunteer Program at Cincinnati Children’s
• Undergrads or grads in speech-language pathology
• Student commits to a min of 4 hours/wk for 12 wks
• Student signs a “contract” with expectations
• Student works half the time and observes half the time

97
 Top of License for SLPs:
Clinical Support
Advantages for students:
• Completes observation
• Gives insight into the “business”
• Is an advantage when applying to grad school or for a job
• Gives student a “foot in the door”

98
 Top of License for SLPs:
Clinical Support
Advantages for the program:
• Lots of free labor to greatly reduces support costs
• Level of skills are usually high
• Chance to select future employees

99
 True or False?

• Progress will generally be faster with intensive therapy.

• Progress will be faster with therapy as needed and intensive practice.

100
 Top of License for SLPs:
Clinical Support
Clinical Support
• Clinical “extenders” (SLPAs, students, parents/family members)
should provide practice to expand patient’s to insure carry-over

101
 Top of License for SLPs:
Clinical Support
Theories of motor learning and motor memory
• Speech requires motor movement that is fast, complex, automatic and
effortless
• This is accomplished by motor learning and motor memory

102
 Top of License for SLPs:
Clinical Support
Theories of motor learning and motor memory
• Motor learning is dependent on:
• instructions,
• trial and error, and
• feedback
• Motor learning is what needs to be done in therapy
103
 Top of License for SLPs:
Clinical Support
Theories of motor learning and motor memory
• Motor memory is dependent on practice
• Develops the automaticity of the movement and ultimate “carry-over”
• Motor memory (through practice) should be done primarily at home, and
not in the therapy session

104
 Top of License for SLPs:
Clinical Support
Practice is not going on at home if the parent doesn’t know:
• …the name of the child’s SLP, or
• …what the child is working on in speech therapy

105
 Top of License for SLPs:
Clinical Support
• Practice results in brain reorganization due to neural plasticity
• Practice is necessary for learning to perform all complicated motor
movements and sequences without conscious thought, for example:
• Ballroom dancing: salsa
• Sports: shooting a basketball
• Playing an instrument: piano
• Speech
106
 Top of License for SLPs:
Clinical Support
• Speech therapy is like piano lessons…If you just go for the lesson but
don’t practice at home, you don’t learn to play the piano

107
 Top of License for SLPs:
Clinical Support
Language learning also requires instructions, study and practice
• Learning a second language requires instruction first, then study and
practice
• Language therapy is the same

108
 Top of License for SLPs:
Clinical Support
• SLPs should not provide “professional” services that nonprofessionals can
do.
• We need to focus on only providing high level, specialize care.
• Practice and drill do not require professional services and should be done
in the home.

109
 Top of License for SLPs:
Clinical Support
• We need to train and coach family members on how to work with
the patient at home.

110
 Top of License for SLPs:
Clinical Support
• The family must be part of the treatment team!
• The family needs to bring the patient to each appointment.
AND
• Work with the patient daily (whenever possible) at home.

111
How do you accomplish that?

112
 “Self-Management”
in Medicine and Healthcare
• Methods by which patients with a chronic conditions can effectively take
care of themselves
• Methods by which families can manage chronic conditions in their
children

113
 Self-Management

“Feed a man a fish, and he’ll eat for a day;

teach a man to fish and he’ll eat for a lifetime.”
(Native American saying, author unknown)

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 Self-Management

To engage families to work with the patient, it helps to use principles

of self-management, including motivational interviewing

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 Self-Management

Motivational interviewing (MI) is a part of self-management:

• Focuses on exploring and resolving ambivalence to change (i.e., I
want to lose weight, but I don’t want to change my eating habits.)
• Determines what motivates the individual to facilitate a change

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 Self-Management
With MI, determine and mitigate barriers to reaching success:, including:
• Transportation
• Child care issues
• Health issues
• Scheduling issues
• Financial challenges
• Communication issues 117
 Self-Management

SLPs can use self-management to improve:

• Attendance of scheduled sessions, and
• Involvement of the parents/family in the treatment process

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 Self-Management
Motivational interview and development of self-management results in:
• Improved outcomes with fewer sessions and lower costs
• Improved patient/family satisfaction

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 Self-Management
Self-management:
• Is an important part of patient-centered care and care
coordination
• Serves as a partnership between healthcare providers and
patients/families
• Helps people with chronic conditions manage their health (or
their child’s health) on a day-to-day basis
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Streamlining documentation
Molly Thompson

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 SLPs spend about 20% of their time on
documentation*
Increasing efficiency can save time and cost to both the SLP and the consumer

* ASHA 2013 Health Care Survey

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 Documentation : a “bottom-up” view

Producing efficient documentation begins with hardware and ends in the cloud

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 Hardware that supports efficiency

Scanner Computer Fax: machine or online

Consider dual side scannerneed remote access?* Online: stores off-site*
Scans large amounts need a PDF-WORD program?
consider on-line backup*
file old reports by diagnosis/treatment
for easy access/ templates
*know your HIPPA requirements 124
 Develop templates to streamline all patient
documentation in a way that meets the needs
of all customers
• Yet is fast to generate and , therefore, less costly to produce

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 Thoughts on documentation
is the required content present and
applicable
are abbreviations understandable/is
there a key?
is the patient’s performance
accurately reflected
is the need for your specialty
evident
do the goals/note coincide with the
diagnosis and treatment codes
is communication between patient
and clinician present
if shared, could others understand
what happened during the
evaluation/treatment and why?
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 Utilize ASHA resources
• Practice Management

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More resources
- Asha Community: SIGS, SLP Private Practice
- Asha Advocacy:
ASHA State Advocates for Reimbursement (S.T.A.R.)
State Medicare Administrative Contractor (S.M.A.C.)
- Other organizations related to setting
- State speech-language-hearing associations
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 Consider your audience
What do the customers want, need and read?

“A report is an act of communication between you and your reader”

Study Advice from University of Reading

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 The Patient/Families
• need clear, concise language that addresses their concerns, your clinical
impressions, a plan of treatment and estimate of the duration of services.

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 Physicians
• More is not necessarily better.
• Reading and signing a patient’s treatment plan is a non-value added service
for the physician. Create a document that is clear and succinct.

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 The Payer
• The medical reviewer is looking for medical necessity, that the diagnosis and
treatment codes and goals are compatible with this. That these items are
clearly stated in the documentation and presented in the most efficient
means possible.

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 The Auditor
• Considers, among other things, that billing and service dates match, proper
signatures and dates are present on needed documentation and that
provisions for service were met according to the contracting agency.

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Reprinted with permission from
the Alaska Speech-Language
Hearing Association
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 The SLP
• intake=evaluation = treatment plan = treatment = daily note
• A good SOAP note creates a detailed snapshot of the session that provides a
framework for further treatment.
• Is the treatment understandable to others ?
• Is your expertise evident?

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Utilize readily available resources

ASHA Practice Portal 136

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 When is the documentation generated?
• Within session (Point of service)
• Outside session

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 When point of service isn’t an option
• Maximizing in-treatment documentation for later generation of the daily
note is a must.
• There may be an app for that! More apps are providing data and reports
• More test companies are creating on-line evaluations that generate reports

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 Electronic Health Records (EHR)

• There is no single format used by all professionals or organizations;

whatever format is used for clinical record-keeping should conform to
federal, state, and local laws and adhere to specific facility standards.
Clinical records should be consistent in format and style and use
appropriate terminology, approved abbreviations, and correct diagnosis
and procedure codes.

Cornett, B. S. (2006, September 5). Clinical Documentation in Speech-Language

Pathology. ASHA Leader.
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 EHR checklist
Documentation management Reminders for re-certifications
Billing Schedule
Customizable Templates for Fax
evaluation, treatment and SOAP
Forward of previous note for editing
Does it require a sign off on the date Good tech support
the service was provided
Price
PQRS support for Medicare Part B

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 Future technologies
• Be an active participant in the development of evolving technologies that will
impact the management of communication and swallowing disorders
• Provide feedback to developers of tests, EHR and apps on what you and
your consumers need and want

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 Q&A
• nswigert@bhsi.com (Nancy)
• Charlette.green@Cherokee.k12.ga.us (Charlette)
• Ann.Kummer@bbhmc.org (Ann)
• Becky.cornett@osumc.edu (Becky)
• polarspeech@yahoo.com (Molly)

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