Tag: skilled nursing

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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10s   by Gene Pizzolato, MS CCC-SLP

10s by Gene Pizzolato, MS CCC-SLP

1. Cookie of choice (for bedside swallow exams)
Lorna Doone

2. BDAE or WAB (for language testing)
BDAE

3. PICA +/- (for scoring)

+  Love the PICA!  In fact, I’ve used it for over 30 years with therapy plans and I call it a “Prompt-Cue Score” (PCS) system. After years of applying this format to my plans I considered it to be my own creation, until the PICA comparison was made by this web site’s Co-founder!. In any case my PCS provides me with great data to monitor progress.

4. Muppets or dwarves (for entertainment purposes only)

Muppets

4a. Favorite individual muppet

Fozzie Bear

5. Worst treatment moment of your career.

Medicaid Audit

6. Best advice you ever ignored.

“Don’t ever accept Medicaid payments”

7. Favorite, most reliable and practical treatment strategy.

I find that visual information organization strategies work well to support
information processing, comprehension and expressive language therapy.

8. Why SLP and not world domination?

Less stress

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

Absolutely not…… well maybe ….. actually “yes” with some adjustments.

 

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

To organize my best therapy practices into a package that could be easily shared.

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

Gene Pizzolato, MS CCC SLP is a graduate of Columbia University and has been in private practice for 30 years. Specializing in working with school age children and adults with developmental disabilities, Gene has been a pioneer in the collaborative approach to treatment. Always a man of vision, Gene has been able to adapt his practice to meet the changing needs of the healthcare and school based communities as well as to continue to expand his clinical skills. As a mentor to countless students and new clinicians, Gene has entertained and inspired us as we endeavor to follow his lead.

Given this opportunity for shameless self-promotion, Gene would like to share with you some sage words of advice:

  1.  Be careful who you stand behind when scheduling your college courses, you may end up pursuing that line of study.
  2. If your business is based out of your home, a mudroom helps facilitate communication with itinerant therapists. You can leave them notes, schedules, reports, etc. And they can leave you cookies.
  3. Professional relationships, (all relationships, really) work best if they are based on mutual trust and respect.
  4. When asking for favors, it helps if you are charming and look like someone famous.

Contact Gene at: genepizz@gmail.com…

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How may I assist you?  Life as an SLP-A

How may I assist you? Life as an SLP-A

by Christine Botelho, BA

I have been a Speech Language Pathology Assistant for over 20 years, licensed in Massachusetts for 4 years (not all states require licensure). Use of Speech Language Pathology Assistants is not allowed in all areas of the Speech and Language field and it is not an easy position to acquire. I have been fortunate to have met Speech Language Pathologists who have given me the opportunities that I have had. I have worked in acute rehab settings, nursing homes, day hab programs, schools and private practice.

As an SLP-A , I have always worked with Speech Language Pathologists. Initially it is difficult to work with a new, unfamiliar SLP because of different treatment styles and expectations. I have found that the speech and language field can be extremely subjective.  A patient, given the same tests and acquiring the same results may have different goals and objectives created by different therapists.  The therapists may desire the same outcome yet approach the treatment from different directions.  Having had the opportunity to work with numerous Speech Language Pathologists has given me countless treatment strategies to refer to while I am working my patients.  Every SLP has their own style of treatment and each patient is an individual- what works for one patient may not work for the other.  It has been helpful to have multiple strategies to try.

My overall responsibility as an SLP-A is to comprehend the recommendations, goals and objectives of the supervising SLP and implement the treatment to maximize the patient’s success. An SLP-A needs to have a basic understanding of the disabilities they are working with. However, their greatest strength is in knowing what materials are available, with an ability to modify and create novel ones in order to motivate their patients.  I feel the optimal use of an SLP-A is to accomplish the “drill work” needed to attain the goals the SLP created.  Therefore, the needs of the patient and their rate of progress determines the ratio of SLP to SLP-A treatment.   ASHA has guidelines for supervision of SLP-A’s and I believe it is important to adhere to these in order to assure the best outcomes. In addition, as this website shows, it’s lonely out there! We need SLPs to bounce ideas off of and to make sure we are on the right track. Our training and experience only gets us so far. The SLP has the education and the responsibility to drive the treatment plan.

Often I look back over my career and remember my patients from the early days and think how much more I could help them, knowing what I know now. If my career has taught me anything it’s that we have to have an appreciation for what we don’t know with the courage to ask questions and continue to search for answers even in the most challenging situations. It is becoming too easy to blame the patients and families for a lack of progress instead confronting our own limitations. I enjoy learning new things in order to help my patients. One reason I like being an SLP-A is that you always have someone to consult and brainstorm with. It is harder to feel defeated when you are part of a team. My best experiences have been working with SLPs that share my ideology and philosophy.

As our field continues to grow and change, I would like to see SLP-A’s working with SLP’s all settings with services reimbursed by all insurances in order to reach as many patients as possible. After all, I bet everyone could use a little assistance.

About the Author

Christine Botelho is an SLP-A with a Bachelor’s Degree in Communication Disorders from Bridgewater State College. When not amazing her school based caseload with a variety of original materials, fun reinforcers and tireless energy, Chris can be found in southeastern Massachusets enjoying time with her family and learning archery.
Contact Chris at sb01@comcast.net.

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The Switch

The Switch

By Michelle Sachs Clapp, CCC-SLP

Back in 1998, I was working with the geriatric population in a SNF setting. The pay was good and I enjoyed my job- at least the direct contact with my clients and the camaraderie with my coworkers. What I didn’t like was the growing amount of redundant paperwork required of me and the increasing demands and tightening criteria of what counted as “direct” or billable time.

I was forced out of this setting by the changes in Medicare standards and the fact that I was a “dinosaur” in the field- I had over 15 years of experience as a speech/language pathologist and it cost agencies or facilities a lot more to keep me on or to hire me than a more recent graduate with less experience. After being “offered” a 33% pay cut along with the promise of a pink slip in a few months, I re-examined my career choice within my chosen field. The job market was not promising for me in light of my years of experience and the pay had been cut drastically, due to the new methods of reimbursement ( direct, billable time as opposed to salaried). I had two young children and although I didn’t have to work full time, I did still have to work to help pay the bills. I decided to apply for a position with a local early intervention agency that was advertising for a speech/language pathologist.

At my interview, I feigned great interest in working with little children, even though I felt that I had little patience for this population. I played up the experience I had from years and years ago working in the Head Start program and with elementary school children. Sure enough, a position was offered to me- 2 days after I was offered a per diem position with 3 SNF’s in a not-too distant town. I accepted the per diem position. Within 2 days on the job, I knew it was a mistake. Criteria for who qualified for my services severely restricted who I could work with, regardless of my professional opinion of who would benefit from my assistance. I could see that I would be spending a lot of time with minimal financial reimbursement. And the paperwork was quite overwhelming as well.

I called the early intervention agency that had offered me a position and indicated to them that I was still interested in them, if they were still interested in ME. They called back and our partnership began.

For the first year of my new career with little ones, it felt like I was paddling upstream; it had been years since I had worked with pediatrics and I was behind in skill, knowledge, lingo, etc. I worked directly with the children and their families during the day and studied and read up on pediatrics on my own in the evenings. After my first year there, I finally felt comfortable enough to start widening my knowledge base by taking on a more varied caseload, reading additional materials about non-speech/language issues with this very young population, and really listening to and doing co-visits with my non-SLP co-workers.

To summarize, I am now completing my 11th year working in early intervention! I love what I do. I feel like I rediscovered my field of work and put my heart into what I do. I feel very alive in my daily work and the rewards are priceless. The pay may not be as much as it is now in SNF’s, but the benefits (being paid with hugs, kisses and holiday photos) more than make up for the lack of monetary compensation. Way back when, when I was applying for this position, I thought that I was faking my enthusiasm about this population but much to my surprise, I discovered that I love love LOVE working with these little ones and their families! I have plenty of patience for them; I guess it was my OWN kids that I had the lack of patience with! Although, as I get a bit older, it gets a bit harder getting up and down off of the floor from my visits, I will continue to do so for as long as I can and will continue to learn about and take on the various challenges that working with the 0 to 3 year old population holds for me.

Michelle Sachs Clapp MA CCC SLP graduated from University of Delaware with a BA in Communications and completed her MA at Ohio University. Since entering the field, she has worked in a variety of treatment settings but finds her current position in early intervention to be her favorite. In addition to her career in Speech Language Pathology, she has honed her parenting skills over the years raising a daughter, son, and soon to be stepdaughter. Her happy home life is fully rounded out by the love and affection of her cat and dog. She has practiced Kundalini Yoga for the last 9 years which maybe how she maintains her charm and humor when life presents unexpected changes.

Michelle is a good friend and an excellent clinician. It was a distinct privilege to work with her so many years ago when our careers as SLP’s were shaken to the core by PPS. I am honored that she agreed to share her method for dealing with the January 1999 reimbursement changes for SNF’s. These regulations continue to test the patience and ethics of individual practitioners across the country. As we prepare for the next round of changes, Michelle’s experience serves as a timely reminder of all the opportunities our profession affords us.…

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Unreasonable and Senseless

Unreasonable and Senseless

By Marguerite Mullaney

Unreasonable and Senseless

The cornerstone words in all rehabilitation treatment plans are reasonable and necessary. They have been the yardsticks by which our Medicare reimbursement intermediaries retroactively determine if a claim for service is covered under the Medicare A benefit or Medicare B plan. Seventeen years ago when I first walked into a nursing home and began to learn the rules for providing rehabilitation services in a Skilled Nursing Facility (SNF), reasonable and necessary were applied to every goal of each individualized treatment plan written for our patients.

I might mention, those plans were handwritten by the evaluating therapists. The goals were often agonized over to be sure they fit the reasonable and necessary parameters and could be measured should proof be needed of the final outcome. Way back in the 90’s, the therapist writing the goal was more than likely to be the person carrying it to completion. PTA’s and COTA’s were utilized as an additional resource but not the primary therapist responsible for weekly updates, monthly recertification, home evaluations, and discharge summaries. In short, they assisted the registered clinician in carrying the caseload. Then as now, Speech Language Pathologist cannot use an SLP assistant at SNF level and receive Medicare reimbursement as our PT/OT colleagues can. This means an SLP carries a caseload in much the same way he/she did almost two decades ago.

The rules changed in January 1999. The Prospective Payment System arrived! It was designed to cut Medicare waste and fraud. It was marketed as a means to control the spending at the SNF level which was rocketing out of control. Many inside the industry puffed about the system forcing ‘smaller players’ out of the market thereby cutting the ‘glut’ of skilled beds. We were being told at the time there were 1000 too many skilled beds here in Massachusetts. The extra beds were alleged to be driving up the cost of care.

I have a question: Our entire economy is based on supply and demand. Has there ever been another industry that drove the costs of services up when the supply was greater than the demand?

We are on the eve of adjustments to the reimbursement system. I’ve been told the regulations are going to get even tighter. To be honest, other than knowing rules will be added in October 2010, my knowledge of the changes are very limited. However, I feel qualified based on almost two decades practicing in SNF’s to make a prediction: Nationally based For Profit Corporations will become the primary providors of skilled care beds across the United States.

I have a second question: Large, nationally based for-profit corporations are created to make money and increase profits for their investors. Who will be paying the biggest piece of that revenue? Individuals? Private Health Insurance Companies? The US Government via Medicare/Medicaid?

I might mention here that regardless of clinical setting, the best reimbursement source for an inpatient rehabilitation stay is Medicare. Yes, the same system that was redesigned to control costs in January 1999. It is the system For-Profit Healthcare Providers want well-represented in their case mix. More than want, they rely on Medicare to make their bottom-line.

Here’s a rhetorical question for those who think I’m overstating the value of Medicare A and B to SNF’s: When was the last time anybody heard an Admission’s Director say they needed to fill more beds with Medicaid recipients?

I’ve watched over the last few years as the terms reasonable and necessary have been morphed into new packaging. Many rehab providers are using software systems that have goals listed and waiting to be plugged into an evaluation. Some software triggers the goal a therapist should pick. There are courses with watch words and buzz words to prep therapist to avoid writing an evaluation or a note with a RED FLAG. I’m a realist. I know those types of formulaic programming are a natural outcome of Intermediary Help Letters, Denials, and the dreaded RAC Audits. There is nothing wrong with giving therapists tools to practice within reimbursement guidelines.

But, something more insidious happened while I was distracted watching the major changes. A phrase entered the continuum of care very casually. In fact, it sounded like a good thing on first blush. It wasn’t until it was applied against the stark white of reality, that I truly understood the danger of the concept.

“We treat all our new admissions as ultra highs until they show us differently.”

It doesn’t sound bad. It actually captures the spirit of America. Everybody gets a fair and equal shot at their bite of the apple. Makes you think the care providers don’t pre-judge based on gender, race, sexual orientation, age, or ability. Sounds like equal protection. But, this is exactly the point where everything goes wrong.

We do an evaluation so we can pre-judge and prescribe the appropriate amount of treatment. Our recommendations are supposed to be based on what the patient is able to do during the evaluation. We must take into account their general health prior to illness, their premorbid level of daily activity, the course of their illness, their age, their family’s goals, and their own hopes for their recovery. We adjust the patient’s goals as the treatment plan succeeds or fails. Weekly notes and monthly recerts are there to keep us and the patient focused on progress, or lack thereof.

However, if the expectation walking in the door before we even lay eyes on the patient is that this very sick individual who has been in acute care for at least 3 midnights is to be able to tolerate a minimum of 35 minutes of treatment per day by 3 disciplines over 7 days with 3 hours of group time being evenly divided among disciplines, then the evaluation is completely superfluous.

Most nurses and aides and family members already know a patient cannot walk, eat, talk, or care for themselves. The therapists’ evaluation is meant to provide a means of rehabilitation and a plan of implementation. Computers are able to generate goals based on assessment data of strength/weakness. Assistants for PT/OT carry out most of the plans of care. And, now registered therapists have pretty much lost their authority to determine how much time is needed per day and how many days in a row are necessary to reach functional potentials.

I fear, we registered therapists across disciplines have just become rubber stamps for a plan of care designed, programmed, and packaged to meet the standards of a reimbursement system extracting the maximum dollar amount for care provided to any patient, regardless of their reasonable and necessary needs.

About the author

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.

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Why we need to show up

Why we need to show up

By Lisa Yauch-Cadden

“Why we need to show up”

As we mentioned in our welcome to this website, Speech Language Pathology can be a profession of great joy, and great loneliness. Often, as sole practioners in schools, hospitals, rehab centers, medical/private offices, and home care settings, we may be the only source of speech and language services available to a child or adult in our community. I have personally worked in hospitals, with no out-patient treatment services, skilled nursing facilities with no/poor access to home care services, schools where families cannot afford additional services through out-patient clinics, and in out-patient settings, where support from the school system has been limited. I have also known clinicians who, all by themselves are the hospital based SLP, the homecare SLP, the school therapist and the out-patient provider. In these situations, we have a huge responsibility to our patients. We may be the only one to diagnose and treat a patient’s problem, or provide a family or physician with needed information. Yet, over the past several years, I have noticed more and more therapists, not taking these responsibilities so seriously.

I have known therapists to cancel appointments for convenience or to avoid a patient with behaviors, therapists that utilize the same treatment approach with multiple patients regardless of individual needs, and utilize the same treatment materials with the same patient, over and over, and then blame the patient when he/she doesn’t make progress. I have worked in facilities where staffing required multiple SLPs to service the same patient on different days, and because no single SLP felt responsibility for the patient, (they were “just covering”, after all), the patient failed to make progress. I have met with indignant therapists, astonished that a payor source would require accountability, prior to paying for services, and I have seen talented therapists leave the field, because they did not want to play by a new set of rules.

In all of these instances, I am reminded that, while as therapists, we think that Speech Language Pathology is about us – our skills, our expertise, our credentials. It is not. It is about the patient. Every client that crosses our path is referred to us, because someone who cares about that person has a question or a concern that needs to be addressed. Someone in that patient’s family, desperately wants them to get better, and often we are the only ones to whom they can turn. We cannot phone it in. We have to show up.

When Mrs. Jones sends her 3 year old autistic son to the school or the out-patient clinic, she is putting her baby in our hands, and hoping for progress. When the homecare clinician sends her patient for an MBS/FEES, she is looking for specific information on the nature of that patient’s dysphagia, as well as recommendations for intervention. When Mr. Smith, an 88 year old man enters the skilled nursing facility for rehab, he is relying on us to understand his Medicare benefit, and entrusting us get him the services he deserves. When we think it is beneath us to be told to provide 35 minutes of care or make sure that we see a patient on Thursday vs. Friday, or write a note that conveys an appropriate level of service, we only hurt the patient, and put them at risk for losing the services, to which they are entitled. And when we cover multiple facilities/multiple patients with multiple clinicians, we need to be responsible for our session, and advance the treatment plan. It is our responsibility to understand our patients’ problems and their payor source and provide skilled intervention to meet their goals.

Now, I know it is hard to bring your ‘A’ game every day, and there are lots of forces that conspire against us (family, kids, traffic, heavy caseloads, limited access to materials, uncaring bosses, budget cuts, etc.). Sometimes patients are needy and families are unrealistic, and our caseloads are unending, and on some days, we have to leave by 3:00 p.m., no questions asked, but we owe it to our patients to try our best, everyday, and honor the implied trust between us. If the situation were reversed, we would expect nothing less.

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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