America is coming of age-and fast. Not only are baby boomers moving quickly toward retirement, but their parents-and, in cases, their grandparents-are surviving to celebrate their 100th birthday. In coming decades it may not be unusual for five generations to gather for a family photograph.
According to a 1999 U.S. Census Bureau report, more than 70,000 Americans today are older than 100, and the estimated rise in the next 25 years is exponential-131,000 in 2010, and 214,000 by 2020. And that doesn't count the baby boom, the oldest of whom won't turn 100 until 2046.
What does that mean for SLPs and audiologists? The need is growing for clinicians who serve geriatric patients, and in particular for speech, language, hearing and swallowing services-dementia management, sensorineural hearing loss, dysphagia, and aphasia, to name a few.
Clinicians working in long-term care are meeting the challenges of health care changes in that setting, including adjusting to a more medically fragile population; greater ethnic diversity; and continued cost containment strategies by industry and the federal government. Another challenge is to meet the growing need for qualified providers.
Skilled Nursing Facilities
More than 1.4 million of the nation's frailest and most vulnerable citizens now reside in skilled nursing facilities (SNFs), according to the Centers for Medicare and Medicaid Services (CMS). Currently, ASHA member data shows that only about 6,000 certified SLPs provide services to that population.
Skilled nursing facilities today are "dramatically different from the stereotypes many people hold about facilities being cold and institutional," says Ed Garrett, an SLP and national director of rehabilitation for Extendicare Health Services, Inc. Federal regulations that took effect in 1990 resulted in "a tremendous improvement in the quality of care and level of staffing, especially in the commitment to rehabilitation services."
Dani West, an SLP with 10 years' experience in long-term care, has run into those stereotyped attitudes from clinicians in other speech-language pathology settings.
"People have a stereotype of the setting that is so negative, and wrong," West said. "I've worked womb to tomb, and would choose long-term care over any work setting.
"Some ask, 'Doesn't it depress you to work with elderly patients?'" she said. "I tell them about work I've done that's much more depressing-a 3-month-old infant who contracted meningitis and had a stroke. Another infant I worked with had a trach and a spit fistula in his neck. He couldn't cry, but would just silently kick his legs.
"I choose geriatrics because I love it. These residents have wonderful stories and I feel that my job is to help give them the best quality of life for their remaining years."
Added Garrett, "Perception lags behind the reality of long-term care. From an administrative perspective our main question is, 'Can we find adequate numbers of qualified staff to meet our residents' needs and help our programs grow?'"
Emerging From PPS
If the SNF industry can't recruit adequate numbers of qualified SLPs, in part it's the industry's own fault. Five years ago, implementation of the Prospective Payment System (PPS) prompted some companies to fire first, and ask questions later about the value of speech-language pathology services in long-term care settings. The PPS, which relies on a per-patient "per diem" or fixed daily payment to cover all patient expenses, was developed as part of the Balanced Budget Act of 1997 to promote management efficiency in service delivery and reduce overall costs. The PPS replaced the unregulated fee-for-service system.
West, who is now the clinical liaison of the Hebrew Home of Greater Washington, located in the Maryland suburbs, recalled the impact of the change.
"Before PPS, we could basically pick our price," she said. "You might have to cover two or three buildings, but you made a comfortable salary. Some cost containment was needed, perhaps, but when PPS came-I hate to use this word, but it's true-it raped the system."
West remembers her shock at the change in her working conditions. "I was pregnant at the time and a full-time employee," she said. "My company told me that I could go to an hourly position with approximately 16 hours a week spread over five days, including Saturday, with lengthy travel times. Or I could take a severance package. I took the severance."
As Ann Horton recalled, "Speech ranks thinned quickly. Our company didn't lay anyone off-but clinicians saw what was happening in the industry and left." Horton, an SLP in Tennessee, is assistant vice president of rehabilitation services for National HealthCare Corp.
ASHA's 1999 Omnibus Survey asked SLPs working in SNFs about "undesired" changes in their employment. The responses are telling-29.5% lost their jobs; 67.9% had a reduction in work hours, and 72.3% suffered cuts in salary or benefits.
There was an exodus of skilled SLPs from long-term care. From 1998 to 2004, the percentage of clinicians in SNFs dropped by nearly a third, from 9.9% to 6.4%, according to ASHA's membership data.
For the SNF industry, the reduction of skilled SLPs was an over-reaction that led to the current recruitment problems.
"Companies panicked, and didn't know how they could do the job with the minutes allocated under PPS. They laid people off first and only later began to understand the PPS," said Pete Johnson, speech mentor for Select Medical Rehabilitation Corp. in Florida. "At that point they tried to hire SLPs back and couldn't find enough qualified providers."
"These companies made a big mistake," agreed West. "The decision makers didn't realize the value of our services. But part of it was our fault too. Some SLPs gave their services away for free, and didn't educate nurses and families."
After her panic subsided, West applied for jobs and was startled by the response.
"I knew I had good and marketable skills, and signed up everywhere as a PRN. It soon became clear to me that these companies had overreacted and cut too many SLPs. As a PRN, I had more work than I knew what do to with. I could have worked seven days a week, 10 hours a day at $45 an hour. One facility offered to pay me $65 an hour and babysit my child," added West.
"Five years later, I'm still getting calls from facilities that need help."
Responding to Encroachment
Some SLPs and administrators are concerned with the rise of "cross-training" of other professionals to deliver services for which SLPs are more qualified, dysphagia services in particular, and worry about the decline in the role and the visibility of SLPs in long-term care.
"We're losing our turf," warns Horton, who first saw the problem as an SLP and now views it as a vice president of a long-term care company. "I've seen us yield cases in areas like cognitive and swallowing disorders to other professionals."
She said recruitment was an ongoing challenge.
"All we can find, for the most part, are contract clinicians who have other work commitments. In Massachusetts and New Hampshire, for example, we cannot find the number of SLPs to deliver needed services.
"Another problem is in the area of caseload," she said. "If we want to keep long-term care as a viable setting, SLPs need to commit to screening, building caseloads, and advocating for their role in delivering services."
The companies that chose not to cross-train now find it easier to recruit and retain qualified providers.
"Our company didn't take that route, in part because of ASHA's practice document that opposed cross-training," said Garrett. "We redoubled our efforts to hire SLPs-and used PRNs, contractors, full-timers, any reasonable option rather than cross-train in dysphagia or other services."
The Mentoring Solution
The possibility of cross training and encroachment-and challenges posed to new clinicians by more complex clinical conditions-prompted Johnson to take a novel approach, a mentoring program.
"Our goal was to recruit and retain qualified SLPs," said Johnson. His company, Select Medical Rehab Services Corp, contracts services to 80 hospitals, 600 nursing homes and 600 outpatient clinics in 24 states.
"The caseload in nursing homes is becoming much more complex," he said. "I've spent a lot of my life in a Level 1 trauma center, and now I see those type of patients in nursing homes. Some facilities are closer to hospital settings."
"One challenge facing new graduates who choose the long-term care setting is potential isolation. Many SLPs are working along in facilities which have several physical and occupational therapists," he said. "Also, less experienced clinicians need support with sicker patients."
After piloting the program in the Tampa area, Johnson expanded its reach and the program now serves much of the state and is expanding nationally. The company provides regional conferences offering ASHA CEUs free to speech-language pathology staff. He holds one-on-one mentoring sessions to work individually with clinicians on areas they need to develop. And there is also a hotline, as well as Johnson's cell phone, that is toll-free to company employees, to get prompt feedback if they need immediate assistance.
"SLPs I mentor in long-term care have remarkably similar needs," he said. "They need clinical decision-making skills, to know how to do a qualified bedside evaluation, listen to the lung fields, and learn about documentation and coding, as well as oscultation and therapeutic strategies.
"They need additional training for long-term care. One person told me she had just graduated and had learned nothing about the deviant swallow."
Florida clinicians are responding, attracted by the mentoring opportunities and a new "train-the-trainer" program that will further expand the mentoring initiative.
To ensure that qualified SLPs are brought back into long-term care, clinicians and administrators with a speech-language pathology background say that preparation and professional training are critical.
For students in master's programs, West supports increased training in dysphagia and other areas of geriatric practice. "We need to be prepared," she said. "I had one class in dysphagia and it was an elective."
Garrett has helped build a free continuing education program at his company. "We offer continuing education in dysphagia and cognition. It's a cost-effective solution because clinicians in long-term care often deal with a complex medical picture."
Another factor is the professional opportunity in management positions, he added, and more externship opportunities.
"We need significantly more SLPs. That is our most serious need," he said. "This setting offers a wide variety of cases, and some are clinically complex.
"It's a good time to be a speech-language pathologist in long-term care. I can't think of a more stable employment situation," Garrett said.
"The picture has really changed in five years. When it comes to hiring, we're truly in a post-PPS world--the industry has adjusted to the payment change and has learned the value of speech-language pathology services. We're hiring under PPS, and will be for years to come."