An increasing number of speech-language pathologists working
in health care settings report employer pressure to provide services that
should be left to clinical judgment—such as frequency and intensity of
services, and type of services—according to ASHA's 2013 health care survey.
The biennial survey tracks a variety of practice-related
issues including salaries, which saw a substantial increase in 2013. Each survey also includes new questions that gauge respondents' knowledge of and experience in emerging issues in health care, such as the use of outcome measures, application of the International Classification of Functioning, Disability and Health, and interprofessional collaboration. The full survey results are available online.
In recent years, SLPs have reported increasing pressure from employers to provide types or frequency of services, regardless of their
clinical judgment about a particular patient.
Although survey questions were slightly different, results indicate a 15
percent increase from 2005 (when 89 percent reported they did not feel employer
pressure) to 2009 (74 percent). In 2013, that figure was 71 percent—down 3
percentage points from 2009.
In 2009, 11 percent of respondents—including 27 percent in
skilled nursing facilities—reported pressure to provide inappropriate frequency
or intensity of services. In 2013, 14 percent reported this pressure, and that
figure was even higher—33 percent—in skilled nursing facilities.
Although clinicians across health care settings express
concerns about productivity requirements or pressures, survey results do not
show dramatic changes in overall trends. In 2011, full-time employees reported
spending 75 percent of their time in direct treatment (individual and group),
19 percent in documentation and 6 percent in other activities. In 2013,
full-time employees reported spending 73 percent of their time in direct
treatment, 20 percent in documentation and 6 percent on other activities. This
statistic remains stable: As far back as 2005, SLPs reported spending six hours
of an eight-hour workday (75 percent) in direct treatment.
Medicare's new requirement to report outcome measures on claim forms exemplifies the increasing demand by all third-party payers for outcome measures to justify treatment. Of the 40 percent of respondents who used outcome measures, the highest percentage was in rehabilitation hospitals (84 percent) and the smallest was in home health (24 percent). The most commonly used functional outcome measures were functional independence measures from the Uniform Data System and functional communication measures from ASHA's National Outcomes Measurement System.
The International Classification of Functioning, Disability and Health, published by the World Health Organization in 2001, is a framework
for describing functional status using the domains of body structure and
function, activities and participation. ASHA adopted this framework as part of
the speech-language pathology scope of practice in 2001, and other professional
organizations and government agencies—including the Centers for Medicare and
Medical Services—are considering it to classify and code patients holistically rather
than by discipline. However, 44 percent of survey
respondents indicated that they had never heard of it, and 44 percent said they
had heard of it but didn't know much about it. As public and private payers increasingly demand objective and comparable outcome reporting across rehabilitation disciplines, the ICF is most often recommended as a possible solution.
For the first time, the survey asked about a growing trend
in health care—the use of interprofessional collaboration to improve outcomes
through communication, efficiency and patient-focused care. Fifty-one percent
of SLPs reported engaging in daily or weekly interprofessional collaboration
for assessment. Even more (64 percent) reported daily or weekly collaboration
for treatment, with 37 percent for documentation, 52 percent for clinical team
meetings, and 54 percent for patient/family meetings. Rehabilitation hospitals
had the highest percentages for all activities except collaboration for treatment,
which was highest for SLPs in skilled nursing facilities (76 percent).
The survey has also tracked for many years whether other
professions are the primary provider of swallowing services, due to concerns
about the variability of training in other disciplines. Only 12 percent
reported that professionals other than SLPs deliver primary swallowing
services, with pediatric hospitals reporting the highest percentage (47
percent), similar to the figures from 2011 (12 percent overall, 44 percent in