Reflections — November 12, 2012 at 5:19 am

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

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

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