Tag: SLP

10’s by Kathy O’Grady

10’s by Kathy O’Grady

1. Cookie of choice (for bedside swallow exams)

    Graham crackers

2. BDAE or WAB (for language testing)

    WAB

3. +/- or PICA (for scoring)

    PICA

4. Muppets or dwarves (for entertainment purposes only)

    Muppets

4a. Favorite individual muppet

    Kermit

5. Worst treatment moment of your career.

    When a home care patient fell while ambulating to the table.

6. Best advice you ever ignored.

    Mom Mom always said, “Never trust a man with a beard.”

7. Favorite, most reliable and practical treatment strategy.

    Putting dysphagia patients’ medication in ice cream to facilitate the swallow.

8. Why SLP and not world domination?

    No, it’s not possible.

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

    No

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

    Teach nursing students and caretakers about swallowing.

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

    Kathy O’Grady MS CCC SLP is a graduate of the University of North Carolina at Chapel Hill. She has spent her career treating adults with neurological deficits which effect speech/language/swallowing/cognition. Her work has taken her through multiple states and a variety of settings. She is equally at home in rehabilitation hospitals, home care, or skilled nursing facilities and can easily juggle the demands of a front line therapist, rehab manager, and supervisor. Truly a gifted resource and valued mentor, I am most pleased she took the time to participate in the 10’s

However impressive her achievements in the clinical arena are, they pale in comparison to Kathy’s greatest skill; Mom. She adopted her daughter from China eight years ago, as a single woman, and is grateful each day for this blessing.

She and her daughter would like to take this opportunity to encourage loving individuals and families to learn more about adoption and support groups working to find children who are alone, the family they so desperately deserve.

Sadly, there are so many more children needing families than there are people able to meet their needs. Wonderful organizations exist to aid those children so they too know they are loved. One such group is Half the Sky which works with orphaned children in China. Their website can be found below:
http://www.halfthesky.org/

Send feedback to Kathy to mullaneycccslp@comcast.net

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I have all the answers but nobody is asking me any questions

I have all the answers but nobody is asking me any questions

By Marguerite Mullaney

“I have all these answers but nobody is asking me any questions!”

The words echoed down the muggy hallway of an Alzheimer’s unit one hot August afternoon as I was hurrying along to see my next patient. They stopped me in mid step. Many times, a patient has managed to say the one thing I needed to hear at a particular turning point in my career. However, on this occasion, the message was shouted by somebody not on my list with no assigned minutes. His sentiment was so poignant and so common it could be a defining human characteristic; the need to share our expertise. It is a want that resonated deep within me and I took a few minutes, unbillable minutes finding the man and asking him a question.

We spend years becoming speech language pathologists. Studies are not enough to get the seal of approval. There are tests to pass, followed by a lengthy fellowship under the watchful eye of another person already judged to be an expert. Even certification and licensure is a process and requires constant education to renew yearly.

Yet, having completed the all basics and continuing to achieve certification and licensure yearly, I find nobody is asking me the question I so desperately want to answer. If I had a chance to answer one question for the next generation of SLP’s, I already know what I want to tell them. It would be the same message given to me by one of my graduate supervisors.

I was her first student. She was my first supervisor with an adult neurogenic population. We spent the autumn of 1987 driving each other crazy and getting in each other’s way. She wasn’t easy to learn from and I wasn’t particularly bright, but we bumbled along with a minimum of chaos. Then dysphagia struck!
Swallowing was a bit new to SLP in those days. Not every clinician was practicing it. I was lucky. My supervisor was confident enough to admit her limitations. She showed me how to research the information I needed to fill the gaps in my university education. There was no dysphagia course offered in my graduate program way back in the dark ages of the eighties. Filling in my theory short comings was as easy as reading; Logemann and Rosenbeck became my bedtime stories for the remainder of grad school.

But, practical application of that knowledge takes…PRACTICE. You need to do an awful lot of awful bedside evaluations before you get really good. You need to see an ocean on aspiration on MBS before you can anticipate the drowning. How does a supervisor get a new clinician from inexperience to expertise without killing anybody? The answer is not, ‘puree and pudding thick liquids for everybody.’
Have the clinician answer this question just as my supervisor made me answer for each of our dysphagia patients 23 years ago: “What swallowing felony has this patient committed to be condemned to puree and/or thickened liquids?”

Too many times lately, I’ve read reports which did not reflect deficits significant enough to justify diet modification. Then there’s an increasingly popular trend in acute care summaries which apply the safest diet for swallowing purposes without consideration of the ramifications to the whole patient. Expensive MBSs performed in which no aspiration was detected or the trials were less than five swallows or limited trials of nectar, honey, and puree or not one compensatory strategy attempted have been in over-abundance in recent years. Bedside evaluations are sent with statements identifying aspiration to the point you must read them twice to be certain imaging was not conducted. In my pursuit of additional information for some of the more outrageous claims, I have heard such depressing excuses as:

1) I stopped the MBS because I was afraid the patient would aspirate.
2) The patient was coughing so I changed him to pudding at bedside.
3) I didn’t try thin during the MBS because at the nursing home he was already on nectar so I started there.
4) There’s no speech at nursing homes so I put her on the safest diet; puree and pudding thick.
5) A suspected timing delay of the epiglottis might be present and could lead to aspiration even though none was apparent on the MBS but to be safe I recommend nectar thick liquids.
6) I didn’t want to recommend something they might aspirate and get sued.
I wish there was no number 6. Sadly, I think it is the driving force behind many of the recommendations. But, I would spread some words of caution to my peers, especially the younger ones. The only thing that avoids litigation is luck. The thing that wins litigation is expertise and documentation.
If you make a swallowing recommendation in isolation of the needs of whole patient to save him from aspiration pneumonia and he goes into renal failure…that’s a big problem.

If you base your recommendations on what you suspect their living arrangements are and you are wrong…that’s a big problem.

If you are practicing limited trial MBS’s and ending them early because you are afraid the patient will aspirate…PLEASE stop conducting MBS and get more education!

Before you alter another diet ask yourself, “What swallowing felony has this patient committed to be condemned to puree and/or thickened liquids?”

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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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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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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