Executive Summary: SLP Health Care Survey 2002
In recent years, health care has changed dramatically due to the growing prevalence of managed care systems and implementation of the Prospective Payment System for Medicare beneficiaries. These changes have had a profound effect on speech-language pathologists (SLPs) working in all health care settings with respect to service delivery, working conditions, caseloads, demographics, and practice patterns. Anecdotal reports and recent data from the Omnibus Survey and Member Counts have shown a declining rate of employment of SLPs in health care settings. To address these issues, and verify the accuracy of anecdotal reports, current and accurate survey data were needed. Therefore a survey of speech-language pathology clinical service providers across health care settings was conducted. The data from this survey may be used for advocacy with employers and payers in addition to providing information that ASHA may use to develop new resources for members.
Development of the Initial Survey Instrument
Draft questions were developed by ASHA staff based on issues and concerns raised by members, volunteer leaders, and the Omnibus Survey. Draft questions were reviewed and revised based on interaction with the consultant (Michael Rosenfeld Ph.D. & Associates) selected to conduct the ASHA Speech-Language Pathology (SLP) Health Care Survey. The survey was pilot tested with initial and follow-up cover letters.
The purpose of the pilot test was to gather feedback on the draft SLP Health Care Survey as well as on the initial and follow-up letters. Twenty-three SLPs working in a general hospital, a rehabilitation hospital, a pediatric hospital, a home health agency, an outpatient clinic, and private SLP offices were represented in the pilot test. Forty-three percent returned their questionnaires. The vast majority of respondents reported the questions and instructions in the SLP Health Care Survey to be readily understandable and the cover letter and follow up letters to be clear and motivating. Several minor changes were made in the survey as a result of the pilot test.
Selection of the Sample
ASHA staff selected a proportional sample of 5,000 SLPs working in he alth care settings from the ASHA data base. SLPs were then randomly selected and stratified across various health care settings. This sample size was selected to ensure a sufficient number of respondents in each setting to allow for separate analyses by practice setting.
Printing and Distribution of ASHA SLP Health Care Surveys
The final survey was printed in scannable format by National Computer Systems (NCS) and provided to ASHA for distribution to the sample of SLPs. The first mailing of the SLP Health Care Survey and cover letter occurred on June 10, 2002. Since the surveys were anonymous, a second survey and follow up cover letter was mailed to the entire sample two weeks later to encourage return of the SLP Health Care Survey. Pre-paid addressed envelopes were included in each mailing. The surveys were to be returned to NCS for scanning and entry of the write-in responses.
Data analyses were to be conducted overall for all respondents and separately for each of the six defined practice settings: general medical hospital, rehabilitation hospital, pediatric hospital, skilled nursing facility, home health agency or client's home (hereafter referred to as home health). Frequency counts were computed for all items as well as means and standard deviations where appropriate. Content analyses were conducted for questions 20 and 33 where respondents were asked to write in narrative responses.
Summary of Results
The survey of SLP clinical service providers across health care settings provided a great deal of information. The data can be broadly categorized into the following broad areas: demographics, work conditions, professional services, workforce information, impact of reimbursement, HIPAA (Health Insurance Portability and Accountability Act), technology use, and ASHA services. Results obtained from each area are summarized below.
The overall response rate to the ASHA SLP Health Care Survey was 42%. The percent of respondents from each practice setting was similar to the percentage of SLPs included in the proportional sample used in this study. Respondents came from all nine geographic regions of the country used by ASHA in its national database with representation of facilities located in metropolitan/urban, suburban, and rural settings. Survey respondents appeared to be representative of the population of SLPs working in health care settings in the ASHA constituency.
Principal employment situation. Forty-six percent of respondents indicated they were salaried employees, 38% were contract employees, and 17% were self employed. A large majority (79%) of the salaried employees reported working full time; one-third of contract employees worked full time; and the majority of self employed SLPs (64%) reported working full time. The percentages of salaried and contract SLPs varied by practice setting. The largest percentages of salaried employees were found in pediatric (76%) and rehabilitation (73%) hospital settings while the largest percentages of contract employees were found in skilled nursing facilities (67%) and home health (45%). SLPs working in home health had the largest percentage of part time contract employees (72%). The largest percentages of self-employed SLPs were found in outpatient clinics or speech/hearing clinics (30%).
Benefits provided by employer. Respondents reported the benefits most frequently provided were paid vacation (80%), health insurance (79%), and paid sick leave (77%). The benefits least often reported as being provided were membership in other professional organizations (5%), state association dues (14%), licensure fees (19%), and ASHA dues (24%). The largest percentage of respondents reporting paid vacation, paid sick leave, and health insurance benefits were found in general medical, rehabilitation, and pediatric hospital settings. Lesser percentages were reported for home health, outpatient clinics or speech/hearing clinics, and skilled nursing facilities. Skilled nursing facilities, home health, and outpatient clinics or speech/hearing clinics were more likely to provide ASHA dues, state association dues, and licensure fees than were those employed in hospital settings.
Level of job satisfaction compared to three years ago. Overall, the level of satisfaction of SLPs was about the same as it was three years ago. Respondents in outpatient clinics or speech/hearing clinics reported the highest levels of satisfaction compared to the past three years. The lowest levels of satisfaction compared to the past three years were obtained from respondents from skilled nursing facilities and rehabilitation hospitals. The percent of respondents indicating they were somewhat or extremely more dissatisfied was 43% for those in skilled nursing facilities and 33% for rehabilitation hospitals. Fifteen percent of the respondents from skilled nursing facilities were extremely dissatisfied compared to three years ago. This was more than twice the percentage from any other practice setting. There was no practice setting where the mean rating indicated they were more satisfied than they were three years ago.
Reasons for job dissatisfaction. Overall, the most frequently cited reason for dissatisfaction was the volume of paperwork. This was cited by a majority of respondents. A majority of respondents from skilled nursing facilities noted involuntary reduction in salaries or benefits without changes in work hours, involuntary increase in number of sites served, and near majorities noted conversion from salaried to hourly PRN pay, and involuntary reduction in paid work hours. A majority of respondents from rehabilitation hospitals noted the involuntary increase in caseload as a major source of dissatisfaction.
Number of hours worked in a typical day. A majority of respondents from general medical, rehabilitation, and pediatric hospital settings and outpatient clinics or speech/hearing clinics reported they worked between eight and 10 hours per day. A majority of the respondents from skilled nursing facilities and home health indicated they worked fewer than eight hours per day.
Productivity requirements. A productivity requirement was defined as the number of hours in direct patient contact divided by the number of hours worked. Overall, 48% of respondents indicated their facility had a productivity requirement. The percentage of those reporting a productivity requirement ranged from 23% for respondents working in home health to 93% for those working in pediatric hospitals. The largest percentage of respondents (44%) indicated that their productivity requirements ranged from 70-79%. While SLPs from pediatric hospitals were most likely to have productivity requirements, these requirements appeared to be somewhat lower than those in other practice settings.
Provision of SLP services on weekends. Overall, 40% of respondents indicated that their facility provided services on weekends. This ranged from a high of 77% for rehabilitation hospitals to a low of 19% for those working in outpatient clinics or speech/hearing clinics.
Percent of direct treatment provided in group vs. individual sessions. Overall, the average percent of direct treatment time spent working with individuals was 91%. The six practice settings reported spending from 89% of their direct treatment time (rehabilitation hospitals) to 98% of their direct treatment time (general medical hospitals) providing individual sessions with their patients. Approximately nine percent of SLPs' direct treatment time was spent working with groups. The most time spent working with groups was in rehabilitation hospitals (11%).
Percent of time spent on interventions with adult and pediatric patients. Seventy-three percent of respondents indicated they worked with adults. Aside from pediatric hospitals, the majority of respondents from the remaining five settings reported that they worked with adults. The largest percentages of time spent working with adults involved treatment of dysphagia, cognitive-communication disorders, and aphasia. The percent of time spent on interventions by SLPs varied by practice setting. Fifty-three percent of respondents indicated they worked with children. A majority of the respondents from pediatric hospitals, home health, and outpatient clinics or speech/hearing clinics reported working with children. The largest percentage of time spent working with children involved intervention for difficulty with language and articulation/phonology. The percent of time spent varied for different disorders by practice setting. Respondents from pediatric hospitals reported spending more time providing treatment for cognitive-communication disorders and dysphagia than did respondents from home health and outpatient clinics or speech/hearing clinics. Respondents from outpatient clinics or speech/hearing clinics were most likely to provide treatment for language and articulation/phonology disorders.
Provision of primary dysphagia services. Eighty-five percent of respondents indicated that no professionals other than SLPs provided primary dysphagia services in their work setting. Pediatric hospitals appeared to be the setting where another professional was most likely to provide these services.
Training or supervising other disciplines in the provision of dysphagia services. Ninety percent of all respondents indicated they had not been asked to train or supervise other disciplines to provide primary dysphagia services. SLPs from skilled nursing facilities provided the largest percentage of respondents (18%) indicating they had been asked to supervise other disciplines in the provision of primary dysphagia services.
Referrals for patients/clients appropriate for AAC services. Overall, 66% of SLPs say they received referrals for AAC devices. This percentage was fairly consistent across practice settings other than pediatric hospitals where 93% of SLPs reported receiving these referrals. These requests were usually handled by referring them to providers outside their facility/setting. The least likely choice in every practice setting was to refer to professionals in other disciplines in their own practice setting.
Use of full time and part time SLPs, SLPAs, and other support personnel. The majority of full time SLPs report working in departments by themselves or with one other full time SLP. This is particularly true for SLPs working in skilled nursing facilities and home health. Respondents from pediatric hospitals appear to be the most likely to work with larger numbers of other SLPs. Similar trends exist for part time SLPs as for full time SLPs. The employment of full time and part time SLPAs appeared to be rare, with 98% of respondents indicating they were not used in their departments. Other support personnel, full time and part time, are employed at a higher rate than SLPAs. The vast majority of respondents indicated they do not use full time other support personnel (87%) or part time other support personnel. Outpatient clinics or speech/hearing clinics appeared to be the most likely to use full or part time other support personnel.
Impact of SLPAs on the provision of services. For those who employ SLPAs, the most frequently noted effects on the way they provided services were more time for direct service and one-on-one service provision, larger caseloads, and increased supervisory duties.
Funded, unfilled positions for SLPs. Seventy-five percent of respondents reported there were no funded unfilled positions for SLPs in their facility. The largest percentages of unfilled positions were found in pediatric and rehabilitation hospitals where 61% and 35% of respondents, respectively, indicated one or more positions were unfilled. The largest percentage of respondents indicating their positions were unfilled for more than six months came from skilled nursing homes (72%) and home health (69%).
Recruiting/hiring of SLPs. The majority of respondents from all practice settings reported having difficulty hiring qualified SLPs. This ranged from a low of 63% for respondents from general hospitals to a high of 79% from respondents from skilled nursing facilities. The most frequently cited reasons for difficulty in hiring were: a lack of qualified SLPs, non-competitive salary and benefits, undesirable working conditions, and undesirable geographic location. Respondents from skilled nursing facilities appeared to have the greatest number of problems hiring qualified SLPs. Write-in comments confirmed the reasons cited above and added concerns such as: location was not close to a university, inefficient recruiting, and unavailability of bilingual SLPs.
Overall, the majority of respondents reported that recruiting was conducted using local advertising and networking with professional contacts. A majority of respondents from pediatric hospitals reported they also use national advertising while skilled nursing facilities seemed to be the largest users of professional recruiters.
SLP student interns and clinical fellows. Forty-five percent of respondents reported they had an SLP intern in their facility within the past 12 months. Respondents from pediatric and rehabilitation hospitals were the most likely to use SLP student interns while respondents from home health and skilled nursing facilities were least likely to use student interns.
Overall, 28% of respondents reported hiring a clinical fellow within the past 12 months. Pediatric and rehabilitation hospitals were the most likely to have hired a clinical fellow while home health and skilled nursing facilities were the least likely to have hired one.
Time spent supervising students, SLPAs, and clinical fellows. Forty-three percent of respondents reported spending some time providing supervision. Approximately half of those SLPs indicated they spent less than 20% of their time in supervision. Respondents from pediatric and rehabilitation hospitals were most likely to spend time in supervision while SLPs from home health and skilled nursing facilities provided the lowest levels of supervision. These results were consistent with the hiring trends in those practice settings.
Impact of Reimbursement
Reimbursement under Medicare PPS. Fifty-one percent of respondents reported their facility received some form of payment under PPS. The percent receiving these payments varied by practice setting with respondents from skilled nursing facilities (95%) and rehabilitation hospitals (72%) reporting the highest percentages, while respondents from pediatric hospitals (16%) and outpatient clinics or speech/hearing clinics (22%) reported the lowest percentages of facilities receiving these reimbursements.
Large majorities of respondents from all practice settings other than those from skilled nursing facilities either did not know or thought there had been no change in the number of SLP positions in their facility/setting as a result of Medicare PPS. The majority of respondents from skilled nursing facilities reported there were fewer SLP positions since implementation of PPS. It was rare to find respondents from any setting who reported that Medicare PPS resulted in more SLP positions being made available.
The majority of respondents from all practice settings agreed that there were more barriers to providing good patient care now than before PPS. Respondents from skilled nursing facilities, general medical hospitals, rehabilitation hospitals, and outpatient clinics or speech/hearing clinics had the largest percentages of respondents agreeing that there were more barriers now while slightly lower percentages were reported by respondents from pediatric hospitals and home health.
The most frequently cited barriers to providing good patient care were pressure to contain services within predetermined limits, increased documentation demands, and reduced length of stay. These findings were generally similar across practice settings. However, reduced lengths of stay was most frequently cited by respondents from rehabilitation hospitals (76%) and pressure to limit referrals for instrumental swallowing studies was most often cited by respondents from skilled nursing facilities (53%). Respondents from skilled nursing facilities were also the most likely to indicate there was insufficient SLP staffing, and fewer opportunities to screen patients. Respondents from outpatient clinics or speech/hearing clinics and skilled nursing facilities were the most likely to indicate there was pressure to contain services within predetermined limits.
Primary reimbursement sources. The largest percentage of respondents indicated that Medicare (36%) was their primary source of reimbursement. The remaining sources of reimbursement listed in rank order were: private insurance (19%), Medicaid (16%), and self pay (8%). The primary sources for reimbursement varied by practice setting. Medicare was the largest reimbursement source for skilled nursing facilities (71%), rehabilitation hospitals (47%), general medical hospitals (46%), and home health (35%). Respondents from pediatric hospitals reported that private insurance (35%) and Medicaid (34%) were their primary sources of reimbursement. Respondents from outpatient clinics or speech/hearing clinics indicated that private insurance (32%), Medicaid (23%), and self-pay (20%) were their primary sources for reimbursement.
HIPAA (Health Insurance Portability and Accountability Act)
The majority of respondents from all practice settings reported they were not at all knowledgeable about HIPAA. Respondents from home health seemed to be least knowledgeable with 72% reporting they were not at all knowledgeable about HIPAA.
Respondents reported that computer programs and software or Web-based programs were not widely used by SLPs for treatment, evaluation, documentation, patient education, or billing in any of the major health care practice settings. The most frequent use across all health care practice settings was for billing. Even here, however, it was generally used only rarely. The highest levels of reported use of computer software or Web-based programs were in pediatric hospitals and outpatient clinics or speech/hearing clinics and the lowest levels of use were in skilled nursing homes and home health. These latter two settings, however, were using computer programs and software or Web-based programs for billing.
Respondents were asked to use a five-point importance rating scale to indicate the importance of a variety of ASHA services. The scale ranged from 1) not important, 2) of minimal importance, 3) moderately important, 4) important, and 5) very important. All of the programs, products, and services provided by ASHA were judged to be at least moderately important. ASHA advocacy on health care issues received the highest rating (a rating of important). Listed below are the programs, products, and services listed in rank order of their overall ratings of importance.
- ASHA advocacy on health care issues (3.86)
- ASHA policy documents (3.48)
- Publications (3.26)
- Health care related information on the website (3.08)
- ASHA CE self study self-study products (3.08)
- Research information (2.97)
- Special interest divisions (2.78)
- Professional consultation with ASHA staff (2.68)
- Other ASHA products (2.60)
- ASHA convention (2.59)
Additional ASHA programs, products, and services suggested by respondents. Respondents were asked to suggest additional programs, products, and/or services that ASHA might provide to enhance their practice in health care. Eight hundred sixty four comments were received. The major categories of responses along with sample responses for each category are provided below.
- Be aggressive regarding speech issues and the government
- Advocate for higher salaries
- Advocate for third party billing
- Advocate for lower case loads
- Advocacy services for families trying to get school services
Education and Training
- More CE about effective treatment and documentation
- Affordable CE courses
- Journals on the Web
- More regional meetings
- More in service via video and internet (laws and ethics)
Efficacy and Other Research
- Conclusive dysphagia research
- Provide more relevant and current treatment information
- Efficacy data summaries for providers
- Studies of appropriate caseload sizes and productivity targets
- Efficacy studies
- Comprehensive treatment and evaluation resource guide
- Dysphagia research into aspiration problems
- More treatment information in Spanish
- Provide more relevant and current treatment information
- More information on the diagnosis and treatment of bilingual students
- Affordable short-term disability insurance
- Group health insurance
- More educational services
- A practical clinical publication
- Registry of SLPs who specialize in an area
- Information for private practice
- Tips to improve efficiency
- Marketing programs
- Help with guidelines on the use of SLPAs
- Grant writing for research
- Let the public know more about what we do
- Let third party payers know more about what we do and how well it works
- More frequent radio and television spots
The results obtained from the ASHA Health Care Survey provided feedback from a representative sample of SLPs working in health care settings. These responses provide ASHA with a more accurate picture of the changes taking place in the health care settings in which SLPs work than can be obtained from the anecdotal information ASHA receives from SLPs calling or writing in with their specific comments or concerns. It is important for ASHA to have accurate information from a large representative sample of SLPs in order to insure that the programs and services it provides meet the needs of the membership.
Highlights of the survey include the first systematic collection of data regarding weekend work activities of SLPs as well as updated information on productivity standards and caseload for SLPs in health care settings. Surprisingly, survey results indicated low levels of use of technology by SLPs. In addition, SLPAs and other support personnel were infrequently used by SLPs in most health care settings. Although levels of dissatisfaction have not changed significantly since three years ago, it was interesting to note that the major source of dissatisfaction across all practice settings was an increased volume of paperwork. Another interesting finding was that almost 75% of all respondents indicated they were not at all knowledgeable about HIPAA (Health Insurance Portability and Accountability Act), which is due to be implemented in 2002-2003 and will impact all health care settings. The highest rated ASHA service was advocacy, which received a rating of important. All of the programs and services were rated as being at least of moderate importance. It was clear that the programs and services currently being offered by ASHA are valued by SLPs in health care settings.
For more information
If you have questions regarding the survey, contact Janet Brown, Director of ASHA's Health Care Services at 301-296-5679 (firstname.lastname@example.org) or Amy Hasselkus, Associate Director, Health Care Services at 301-296-5686 (email@example.com).