What does the day bring for a speech-language pathologist in a skilled nursing facility? The chance to bolster a patient's quality of life and independence. And also the challenges of an ever-increasing caseload and ever-diminishing time.
Just to name a few scenarios that could complicate your day: A patient you just discharged has a choking episode and needs an immediate consult. A client not scheduled for treatment today demands your help so that she can have some water. Nursing aides can't get a patient to follow directions, so they call you in to help with communication.
Meanwhile, you still need to see all the patients already scheduled today—and to thoroughly document your treatment and code it correctly per the latest Medicare regulations. How to handle this? There's no magic fix, of course, but there are some strategies you can use to help better manage your load. For example, you can:
Document treatment at the point of care. Set treatment goals and record case notes during sessions with patients. This way, you include clients in creating goals and assessing their progress toward them, in accordance with patient-centered care (see the March ASHA Leader article, "Document It On the Spot"). You also ensure that you complete documentation quickly and accurately. In cases in which cognitive and language impairments affect communication skills, include caregivers and families. Remember that—per Medicare's new functional reporting (G-codes) for outpatient therapy services—you want to select a reporting area based on greatest priority for the beneficiary. For ASHA guidance on G-codes, see our table.
Learn about Medicare coding. Know ahead of time what documentation you need to justify services. Refer to Chapter 15 of the Medicare Benefit Policy Manual, "Covered Medical and Other Health Services" [PDF]. Also review the national coverage determinations and local coverage determinations for speech-language pathology.
Reach out to other providers. Educate others that you need to know about residents entering early stages of functional decline. Learn to speak the language of nursing aides and other medical staff. For example, instead of asking, "Are any of the residents having swallowing problems?" ask "Are any of the residents holding food in their mouth, losing or spitting foods from the front of their mouth, throat-clearing or coughing at meals, having shortness of breath or reduced oxygen saturation at meals?" Establish regular communication channels with patients' dietitians to discuss weight; minimum dataset coordinators to learn about documented declines in hearing, speech, vision, cognitive patterns and swallowing/nutritional status; and the rehab director to discuss new admissions and screening results.
Get creative about scheduling. Take advantage of daily facility routines and activities to squeeze in treatment sessions. For example, incorporate your cognitive interventions during bingo or other facility activities, and use meal and snack times for treating dysphagia and establishing a dining program.
Promote carryover of skills. Engage patients, staff caregivers and family members early on in discussions about anticipated outcomes and dysphagia interventions. As stipulated by Medicare, education of staff, clients and families should begin at the start of care. Also, work to develop restorative nursing programs and functional maintenance programs to help patients achieve the highest possible functioning.
When training caregivers, encourage them to show verbal understanding and demonstrate techniques you've taught. For example, you could teach restorative dining to the patient and caregivers, encouraging use of swallow strategies that allow the patient to consume the least restrictive diet on discharge. Or you could train nursing aides about giving clients choices
rather than asking open-ended questions. You can also break tasks into smaller chunks to increase the residents' auditory comprehension skills during activities of daily living.
These tips may help you better manage your caseload in the skilled nursing setting and help you establish and maintain a fluid process from start of care to discharge and beyond.