Tag: CFY

Conflicting Emotions

Conflicting Emotions

by Marguerite Mullaney, MS CCC-SLP and Lisa Yauch-Cadden, MS CCC-SLP

This entry of REFLECTIONS brings the founders of this website together once again following some disappointing news…

Lisa Yauch-Cadden and I met in 1999 when the SNF world was freezing to death in the new ice age of PPS. I was doing per diem with every company operating in MA because all the full time positions vanished between midnight December 31, 1998 and 12:01 am January 1, 1999. Lisa was the SLP Regional for a company that no longer exists and whose name is better left in the past.

My life was in a spiral. Lisa doesn’t know, at least she didn’t until she read this draft, how close to pulling the plug on my own life I was that winter day in 1999 when we spoke by telephone. The telephone was one of those super heavy Nokias which could be used as a weapon if some ruffian set upon me. I was in more danger from the internal bully egging me on to end my temporary misery with a permanent solution.

I was in the front seat of my car watching the gentle waves of Dorchester Bay near Castle Island in South Boston. Lisa was driving somewhere in southeastern MA. She was giving me a quick run down on what PPS was all about and how it would impact my service delivery.

To be honest, I was only half listening. My mind was stuffed with grief over my father’s death just 19 months before and all the things he left undone: a distraught and broken wife, a physically handicapped son, a mentally ill son, an incarcerated son, and very tiny grandchildren who needed every adult in their little lives who could feign normalcy, to do so. Then there were his bills. Hundreds of thousands of dollars with nobody to pay them except my sister and me. So, the collapse of healthcare and the resultant destruction of my steady, reliable paycheck could not have come at a worse time. Yet, there I sat in the frigid cold front seat of my car, having decided that today I would not just walk into the sweet Atlantic and end it all, listening to the confidence Lisa expressed about the future.

Surely, she was a mad woman.

Her advice resonated though. It made wonderful sense in a world of senseless new rules. The advice was, in fact, brilliant. It gave me a path forward from the professional and personal hole I was being consumed by.

“Just treat your patients. If we all just take care of our patients then everything else will flow from there.”

So, I decided that this SLP radical I was talking to, while she tooled around in the land of Lizzie Borden, might be on to something. And, if she wasn’t, I could always walk into the sea on another, warmer day.

That year, following Lisa’s ‘just treat’ advice, I made more money than in the previous two years or the following year as a full time employee for one company. The success of it went very far in restoring some stability in my still overly complicated life.

Lisa and I didn’t touch base for a few years following that call. The company she worked for folded and her supervisors opened a new group. They were planning to do it right. Patient care first. I initially inquired about work with them but the office manager was kind of … difficult and the pay rate was a little less than ok. But, then after a few months they advertised for a per diem at a place less than 15 minutes from home. I could take a few dollars less and a snippy receptionist for a clean SNF 10 miles from my front door.

Lisa met me on September 15, 2001. The country was in chaos. I was less suicidal than during our previous conversation but everything else in my life was just as complicated. It would have been the 48th birthday of my brother. He died 10 months before, leaving my sister and me heartbroken and lonely. I thought I was meeting Lisa for an interview. Lisa arrived with the employment forms and launched into my Orientation while I filled the materials out. When I asked her if this was an interview, she looked stunned.

“We already know each other. Why rebuild the wheel? Besides, there are patients waiting to be treated.”

So, that first day was Interview, Orientation, an eval and three treats all wrapped into one. It sounds crazy but Lisa’s confidence in “just treat our patients” made it seem silly not to do it the way we had. Besides, it was great to hear that certainty of the path forward again.

For the next two years Lisa and I developed a model which placed one SLP in each SNF. The ratio of therapists to buildings went from one therapist to nine buildings to one therapist per one and a half buildings. We were flourishing and growing. It was amazing. We started a CF program and launched the careers of some truly remarkable therapists. We established clinical relationships that flowed into lasting friendships. So much so, that my Facebook list of friends and family has almost fifty people I met through the company. I am super selective about work people being on my feed because I don’t like to blur lines, so it stunned me when I counted them up yesterday. It was such a period of exciting professional growth that I think of those days when I personally struggled with a family in crisis as some of the happiest days of my adult life.

But, all good things end.

The cash flow wasn’t enough for profit margins. The owners, who once prided themselves with answering the phone in the mornings, hired somebody to GROW the business. That is a euphemism for driving revenue to increase profits at all costs. The new management person quickly ended the homespun, family business approach. All communication went through her. The owners were not allowed to talk directly to staff. They stopped answering the phone. Which was easy for them to do because their sole office staff swelled to more than twenty full time people. Lisa left before me. I wandered away from the management end but lingered to treat. Eventually, the cultural shift drove me away completely.

It is easiest to describe the environment the company became like this: staff in the company office, which they dubbed corporate even though it was not a corporation, behaved as if their jobs would be better if there were no pesky customers and annoying therapist to call and cause them trouble. And, decisions about direct care which are best made by treating therapists and people who actually see the patients were being challenged by people in an office miles way reviewing records. The challenges were never to provide less billable units.

One conversation I had went something like this:

CORPORATE TYPE: The patient needs 50 min by all three therapies today.
me: Can’t do it.
CORPORATE TYPE: It’s your job, you will do it.
me: The patient is sick. I can’t do any minutes with her and neither can the others.
CORPORATE TYPE: Did you check to see if you can do education.
me: I did more than that. I held her hair back while she vomited and I got her a cold cloth for her forehead. None of that is billable. Maybe you should go up and see if she has stopped projectile vomiting yet.
CORPORATE TYPE: I’m not going to do that.
me: Somehow I knew you’d say that.

None of us saw our client that day for treatment. We all spent time with her trying to keep her comfortable which was nice for both her and the nurses. She passed away that night. So, the minutes not given to treatment didn’t matter even one little bit. I called the corporate type to let her know. She was unmoved by the news.

So, why am I babbling about a job I left in 2007? The FBI raided their offices on Thursday.

I met some of my best friends at that company. Lisa is not only a friend but she is a business partner and mentor and all around reasonable voice in an unreasonable world. The work she and I did there was life changing for staff and patients alike. The care model we developed is still being used by the national companies who won contracts at the homes our former company lost. So much to be proud of. So much to be grateful for.

Yet, today I am embarrassed to have the name of that company on my résumé.

It is unreasonable to feel this way. I left long before the rumors about ethical decline really picked up steam. My story pales in comparison to some of the war stories others have told.

Still, I don’t like how close my name sits to their name on the annotated history of my career.

It has yet to be determined if there is anything to the allegations. The FBI under the direction of OIG is investigating. There have been no findings to date. We are a country of laws. Innocent until proven guilty is the cornerstone of our due process. I firmly believe this to be true.

But, I feel betrayed by the news of the investigation.

I am left wondering how a company that started with the goal of doing it right, and was so single minded about patient care that it pulled me back from the brink of self annihilation, could end up with armed FBI agents storming in the front door to remove boxes and computers.

How did the owners let all those good people I met there, who they had the good sense to hire, down? How did they lose the key to greatness? How did they let themselves be lead astray from just taking care of our patients?

How?

And the answer to that question of course is…MONEY. Money lead them astray and locked the door to greatness. Money let down the staff and the supervisors. Money tried to tell clinicians how to treat their patients. And Money forgot that patients and clinicians are people and need to be treated with respect.

When I began in the company, it was as Marguerite described: owners with simple, straightforward ideas about how to build a better mousetrap. Establish strong relationships with your contracts and staff. Do the right thing. Treat the patients according to their needs. Follow the rules. When you make a mistake own it and when your staff make a mistake, stand behind them.

When I spoke with Marguerite over the phone all those years ago, I believed what I said. If you treat the patients, the rest will follow. I still believe that. The best way to make money is to do a good job. If you want to make more money, do a better job and if you want to make the most money, do the best job of all of your competitors. What this means to me is that you understand your patients’ problems, you know how to treat them, you exhaust all possibilities in your quest to help them get better and you understand their funding source as it applies to your services.

I think where people may go astray is in their determination of how much money is enough. How much do you need to be successful? How many corners can you cut in the name of efficiency? When do your cuts compromise patient care and how long will it be before those cuts compromise your integrity?
And that is the slippery slope on which so many clinicians have found themselves.

The changes in healthcare have made it harder for clinicians to stand against the tide. I think this is particularly true for SLPs. Rarely is our supervisor in any setting an SLP. When we have a concern, who is there to stand up for us? Who understands our perspective?

A few years ago, I was looking for a new job. I did a phone interview for a large rehab company. I was told that none of their regional supervisors in New England was an SLP. My immediate, uncensored reaction was “That’s outrageous!” I suspect that the OT that was interviewing me at the time did not share my view because I never heard from that company again. But it is outrageous.

When Marguerite talks about the systems we set up, the programs we created and the staff we trained, one of the things we prided ourselves on was making sure our staff knew that we did not want them to do anything they were not comfortable doing, and if someone was asking them to do something that didn’t seem right, they needed to:
1). not do it, and
2). inform us so that we could look into it.

But that is harder now. Our economy requires job security. It is not so easy to walk out defiantly and directly into another position. And healthcare is changing. But that shouldn’t mean our core values have to change.

I sincerely hope that the investigation into our former employer turns up empty; that the founding principles of the company to which I devoted so much of my career remain intact. When I left, I was proud of the work I had done.
No one can take that away.

About the Authors
Marguerite Mullaney was born and raised in and around the Boston area. She continues to make her home in the Commonweath and rarely finds it necessary to travel beyond the 128 belt. Her undergraduate program was completed at Bridgewater State College and she attended Northeastern University for graduate school. Adult neurological disorders has been the primary focus of her clinical practice. Her vast knowledge of the field, thoughtful, pragmatic approach and incredible sense of humor have enlightened and inspired her patients, staff and colleagues for over 20 years. Contact Marguerite at mullaneycccslp@comcast.net.

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com. ……

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When Rehab Came to Long-Term Care

When Rehab Came to Long-Term Care

For this entry of REFLECTIONS, the founders of this website decided to take a moment to reflect on our own careers in the field of Speech Language Pathology, particularly that portion that brought us together.

Way back in the very late 1980s/very early 1990s, we were both moonlighting as contractors in long-term care.  We had both come from in-patient rehab settings working with brain-injured adults and were looking to expand our skills.  Back then, SLP’s were required only on an ‘as needed’ basis in nursing homes. PT’s were required 6 hours a month and OTs were regulated to 4 hours.  There were no rehab teams, because rehab didn’t happen in nursing homes.  Nursing homes were for custodial nursing care.  If a patient had a problem, the home would call us. We would swoop in, do an evaluation and leave a long (sometimes very long) list of recommendations for the nurses to carry out.  We didn’t treat the problem.  Follow up was PRN – at the request of the nurse – if the problem didn’t resolve, given our extensive recommendations.  Thinking back, it is shocking how much we didn’t do.  Even more surprising was the fact that the head injury facility where one of us worked full time (in a department that included two other full time SLPs and two full-time SLP-As) actually occupied three wings of a four wing long-term care facility, and in five years of providing full time care, our department was called to the nursing home wing only once.

Then things changed.  In order to cut costs and defer care away from high priced hospitals, insurance companies and the federal government’s medical insurance plan, Medicare, began to reimburse nursing homes for rehabilitative care.  It was pretty much a pass through arrangement which allowed nursing homes to charge a fee for rehabilitation services which Medicare then paid.  This opened up huge opportunities for nursing homes and contract rehabilitation companies that provided rehab staff
(PTs, OTs and SLPs) to nursing homes.  This was now the mid 1990s and we found ourselves setting up departments and policies and feeding programs and language therapy in facilities that had never had them.

A population we always thought we’d just dabble in, in a setting no one ever liked, we began to love.  And then we started to teach other people (students and CFYs) to love it.  Senior citizens are awesome.  They are wise and hilarious and generous and aggravating. They allowed us into their home (the nursing facility) so that we could care for them.  It was a joy to see them improve, heartbreaking when they didn’t and an honor to shepherd them through difficult times as they approached the end of life.  The process transformed traditional nursing homes where people went to die into skilled care facilities where people lived, got better, sometimes went home or stayed and lived their lives in a place they could call home.

Then came more change.  Enter the Balanced Budget Act of 1997.  The Balanced Budget Act of 1997 was an omnibus legislative package enacted to balance the federal budget by 2002.  The Act resulted in $160 billion in spending reductions between 1998 and 2002 with Medicare cuts responsible for $112 billion of that total.  This became the real test of our love of long-term care.  We now of course, had to do more with less, but this is also when our programs started to grow and coordinate with nursing and our fellow rehab professionals.  We were a smaller more mobile band of therapists working hard to treat a population that viewed the nursing home as a short-term stop on their road to recovery. Before our entry into rehab in long-term care, no one would have ever thought that a patient would return to the community once they entered a nursing home.  Now today, most rehabilitation following surgery, strokes or general hospitalization happens in nursing homes for people over 55.

As we look back/reflect on this part of our careers, we are pleased to have been a part of the group of professionals who changed how healthcare was provided in the US. Our work extended care to millions of neglected older Americans warehoused in institutions. We improved their lives in terms of survival and opportunities to return home. In fact, you would be hard pressed to find a nursing home in the U.S., accepting Medicare dollars that does not have an SLP as part of their team. It has been our privilege to participate in this leap forward in service delivery to provide a better quality of life for our Nation’s most valuable living treasures: our parents and grandparents.

About the Authors

Marguerite Mullaney was born and raised in and around the Boston area. She continues to make her home in the Commonweath and rarely finds it necessary to travel beyond the 128 belt. Her undergraduate program was completed at Bridgewater State College and she attended Northeastern University for graduate school. Adult neurological disorders has been the primary focus of her clinical practice. Her vast knowledge of the field, thoughtful, pragmatic approach and incredible sense of humor have enlightened and inspired her patients, staff and colleagues for over 20 years.  Contact Marguerite at mullaneycccslp@comcast.net.

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com.

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R-E-S-P-E-C-T

R-E-S-P-E-C-T

By Lisa Yauch-Cadden

“R-E-S-P-E-C-T”

As someone who grew up in Motown, I know a little bit about Aretha Franklin and her mantra. As a clinician who has been around awhile, I know a lot about why it is so important.

In our business, we deal with all kinds of people: patients, families, physicians, nurses, therapists, case managers, social workers, insurance representatives, students, etc. Like any business that involves personal interaction, everyone has a perspective, an agenda, a point of view. In our role as a diagnostician/therapist, we may need to bring all of these perspectives together, and if we can’t bring them all together, we certainly need to appreciate them. Every person that works with/interacts with our patient has a perspective about that patient, and those perspectives may be important to us. When I evaluate a patient, I always try to ask them what they think the nature of their problem is. I also ask their family members: “What problems do you see?” “Why do you think they are occurring?” I canvas the nurses and the CNAs. I consult with the physician. I ask the treating clinician (CFY, SLP-A) who may be working with them. All of these people invariably know the patient better than I do and their insights are important to me and to the patient. When I come to a conclusion, I let patients/families know, “Here’s what I think”. I seek confirmation, when I can, (e.g., “Does this make sense with what you see at home?”). It provides for a better recommendation, usually leading to one the patient can live with (think: modified diet/thickened liquids).

I also have used this approach as a manager and find that staff generally do a better job when you treat them with respect. I know, novel concept. Having worked for managers that don’t share this philosophy, however, makes me think that this is may not be an intuitive strategy for some people. The concept, however, is simple. People have their own opinions and perspective, as do you, and like you, people think that they are right. As a manager, you need to appreciate that, and sometimes solicit that perspective, in order to come to a shared conclusion. Like you, people need to be validated. Once you let them know that their perspective has value, they are much more likely to hear your side of the story. And when that side doesn’t necessarily agree with theirs, or doesn’t give them what they want, you are less likely to have problems afterward, as long as you’ve told them the truth.

And that’s the second part of the equation: Tell the truth. Respect the person you are dealing with enough to let them know the truth. If they know you are being truthful, even if they don’t like what they are hearing, they are more likely to accept it. Isn’t that how you would like to be treated? Imagine what a world it would be if everyone acted this way.

About the author

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com. .

If you have something to say, please submit your article for consideration to lycslp@gmail.com. .…

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10’s by Lori Yauch

10’s by Lori Yauch

For our inaugeral column, we have selected Lori Yauch, a Speech Language Pathologist of over 20 years, practicing as an independent Consultant/Clinician in the Tampa Bay Area. Lori has a unique product that she would like to share with her colleagues, but in order to do that, she must first answer the 10 ‘no ifs ands or buts’. We hope you enjoy her responses as much as we did.

1. Cookie of choice for bedside swallow exams:

Lorna Doone

2. Preference for language testing BDAE or WAB:

BDAE

3. +/- or PICA for scoring:

Modified PICA (10 down to 1, but I forget what 2 is. I think it’s the same as 6, so why use it? You get more credit with 6, or maybe you just get egg roll. I can’t remember)

4. Muppets or dwarves for entertainment purposes only:

Muppets

4a. Favorite individual muppet or dwarf:

Elmo

5. Worst treatment moment of your career:

Any moment during my first job. I was a new grad and had to move away from home, living truly on my own for the first time. I lived in one state and crossed the border daily to work. My CFY Supervisor was selfish, unsupportive and certainly, ineffective as a teacher. I think it was her mission to find fault in every move I made, both in the clinical arena and in the building environment. I used a scooter to assist in my mobility and was written up for, among other things, the way in which I moved about the facility. By the end of 6 months I resigned. I heard later, she fell and was in a wheelchair for a time. You know what they say about paybacks! I moved on to greater and greener pastures. Years later I am a respected clinician, having supervised many students and CF’s and am here offering insights into our field Things really do have a way of working out.

6. Best advice you ever ignored:

I don’t typically ignore advice. However, there was a time when I was looking for bigger and better things. A friend suggested I come to her company, I considered it carefully and just as I was about to make the decision to move on, the company called and rescinded the offer. As it turned out, better offers came and when the time was right, I moved on.

7. Favorite, most reliable, and practical treatment strategy:

Masko Maneuver

8. Why SLP and not world domination?

SLP is world domination. One patient at a time.

9. Would you do it all over again exactly the same way?

Yes. If I hadn’t, I would not be where I am today. I learned from every experience. What I want and what I don’t. I have a good career balanced with a good life.

10. What one thing do you still want to do before your career goals are completely achieved?

Publish my manuscript. Movies and Music: A Clinician’s Guide to the Classic Movie Musical and Group Activity (which segues very nicely into the next question)

SHAMELESS SELF PROMOTION IN 30 WORDS (there actually is no word limit really so say whatever you want):

As clinicians in long-term care or adult rehab settings, we have all been faced with the necessity of providing group activities to our residents/patients. In an effort to come up with a new and innovative group idea, I decided to bring my passion for classic movie musicals and my job together. In conjunction with the Activity Dept. at the skilled nursing facility in Florida, where I was one of 3 speech pathologists, Movies and Music was established. In running this group I began to realize with the right material and right level of function, watching a movie which was once a sedentary activity, could be quite interactive. The interaction fostered increased communication, use of language, pragmatic skills, conversation and long term memory.

With this in mind, together with further observation that no group like this existed in any of the facilities I visited as a consultant, Movies and Music: A Clinician’s Guide to the Classic Movie Musical and Group Activity was born.

The guide is divided into 12 sections according to the calendar year and centers on a specific movie for a given holiday in the month (New Year’s Day, President’s Day, St. Patrick’s Day, etc). The films were chosen specifically for their ability to promote interaction.

The group size is generally 4 -10 patients with mild – moderate cognitive impairment. Diagnoses may include: Right/Left Hemisphere CVA, TBI, Dementia, Parkinson’s Disease or any other diagnosis at the Group Leader’s discretion.

Field testing completed during 2008-2009, yielded positive results with clinicians stating:

“ I highly recommend Movies and Music to any clinician working with individuals with mild to severe communication deficits….I look forward to being able to include this in my future plan of care at my facility.” Jane Fitzgerald House, M.S., CCC-SLP

“Assessment of the group dynamics indicated increased motivation, interest and curiosity which resulted in increased expressive language skills. … Group participants stated it was fun and interesting.” Lisa Mathers, M.S., CCC-SLP

Movies and Music: A Clinician’s Guide to the Classic Movie Musical and Group Activity is available for purchase. Please contact Lori Yauch at moviemaven1@verizon.net.

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