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Health Care Issues Brief - Acute Care

Please note that in the current rapidly changing health care environment this information is subject to change, particularly in the area of reimbursement.

Developed by the Ad Hoc Committee on the Changing Role of the Speech-Language Pathologist Across the Health Care Continuum. Updated in November, 2005. Significant changes to the original text are indicated by *.

Working In An Acute Care Medical Setting

Preface

ASHA's Executive Board appointed an ad hoc committee for 1998-99 on the Changing Role of the Speech-Language Pathologist across the Health Care Continuum. The charge of the committee was to provide current, relevant information about the rapidly changing arena of speech-language pathology service delivery across the broad spectrum of health care. The committee members prepared a series of issue briefs on four different settings: acute care in a medical setting; inpatient rehabilitation hospitals; long-term care and home care. The members of the committee included: Carole Roth, chair; Leora Cherney; Kathleen McAvoy; Gwen Reeves; Martha J. Smith; Carmen Vega-Barachowitz; and Louise Zingeser, ex-officio. Nancy Creaghead, 1997-99 Vice President for Professional Practices in Speech-Language Pathology, served as monitoring vice president.

General Introduction

Health care across all settings has been experiencing a dramatic and unprecedented upheaval. The causes of this unrest are multiple, but largely relate to changes in reimbursement, demands of regulatory bodies, and patient factors. Fundamental changes in private and public systems of reimbursement, primarily a shift from fee-for-service to capitated and discounted arrangements, have been the most powerful change force affecting health care. The recent changes reflect measures to contain escalating health care costs, and they affect all aspects of health care delivery.

Private reimbursement systems began to move to one of several managed care models in the late 1980s, and now account for the majority of health plans nationwide. Public payers, predominantly Medicare, have also restructured their reimbursement systems. The Balanced Budget Act of 1997 mandated new methods of Medicare payment for most health care settings. In addition to direct cost-containment efforts, concerns about fraud and abuse have added to the drive to tighten payment mechanisms.

As these payment systems have been introduced, service delivery has by necessity changed. The most immediate and pronounced effect has been a closer examination of the nature, frequency, necessity, and costs of services. In addition to payers, health care providers must also respond to the requirements and expectations of various regulatory bodies. As service delivery changes, maintaining quality of care becomes an increasing challenge. Federal, state, and local licensing bodies; health care facility accreditors; credentialing entities; and institutional policies and procedures all may place demands on the provider. Factors that are frequently evaluated may include clinical competency, adequacy of documentation, quality of care, and measures of consumer satisfaction.

Patient factors are changing as well. Overall, the number of older Americans is rapidly growing, with accompanying shifts in the nature and severity of their illnesses. As America's population changes, many more patients from culturally and linguistically diverse backgrounds are being treated. Patients and families are becoming more involved in treatment decisions, and are seeking information and accountability.

This mix of changes in reimbursement, regulatory, and patient factors pose multiple challenges to providers. The nature of these factors as they affect speech-language pathology practice in an acute care hospital setting will be examined below.

Changes Impacting Speech-Language Pathology Practice In An Acute Care Medical Setting

Reimbursement Issues

Health care reforms directed at reducing cost have resulted in changes in the way hospitals are reimbursed. Hospitals negotiate with insurance companies to obtain reasonable payment for services rendered to enrollees. At the same time managed care has spread throughout the country defining health care packages for consumers that specify a network of physicians and hospitals. As a result of the Balanced Budget Act of 1997 Medicare reimbursement per patient has been reduced.

Most speech-language pathology services provided in an acute care setting are not directly reimbursed. Medicare reimburses hospitals based on a predetermined amount of money defined by the patient's diagnoses (DRGs-Diagnostic Related Groups) regardless of the services the patient receives during hospitalization. Under the DRG payment system the hospital is paid one lump sum of money for a specific diagnosis. Providing more services to the patient does not result in increased reimbursement to the hospital, but instead increases risk for the hospital to lose money. An exception to the DRG-based system are some private payers, who may negotiate a rate with the hospital, or patients who have no insurance and either receive "uncompensated" or free care, or those who are "self pay" and pay 100% of charges out of pocket.

Trends

The following trends have been observed across the country as a result of decreased reimbursement to acute care hospitals:

Decreased length of stays
Decreased referrals to specialty services
Creation of clinical pathways to standardize care and facilitate timely care
Creation of new positions, such as case managers or patient care coordinators to ensure efficient quality care
Increased contractual relations among hospitals, physician groups, and managed care organizations

Regulatory Issues

1. Joint Commission

The Joint Commission accredits most hospitals nationwide. This regulatory agency reviews or "surveys" hospital programs for their compliance on standards related to quality care. The Joint Commission accreditation process has been recently revised to include unannounced surveys and periodic performance reviews, among other changes. Patient safety has also become a focus area, with National Patient Safety Goals updated each year.*

Examples of Joint Commission standards of quality care include:

Provision of care
Medication management
Leadership
Management of information

2. Other Regulatory and Accreditation Processes

Medicare reviews consist of a more stringent process for facilities that are not accredited by Joint Commission.
State and local regulatory reviews also influence institutional accreditation and reimbursement.
ASHA members must abide by the Code of Ethics.

3. HIPAA (Health Insurance Portability and Accountability Act of 1996)*

Regulations apply to covered entities, but it is advisable that all SLPs familiarize themselves with HIPAA rules
Administration simplificaton regulations focus on three areas:
- Privacy of protected health information
- Electronic transfer of health data
- Security of health information
Impacts all forms of communication of health information (electronic, written, oral), as well as billing and information storage
Violations may result in fines and penalties

Patient Factors

Speech-language pathologists are experiencing changes in their patient population as the nation's demographics are changing.

1. Aging Population

People are living longer.
End of life is being prolonged through medical advances and technology.
Different issues are being considered: quality versus quantity of life and risks versus benefits; e.g., eating for pleasure despite risks.

2. Acuity

Patients with acute illnesses are surviving longer due to expanded medical knowledge, available procedures and medical technology. Therefore speech-language pathologists are seeing patients with higher acuity levels.
Speech-language pathologists are being asked to address increasingly complex questions (e.g., managing a patient with dysphagia following a gastric pull-up procedure).

3. Advances in Medicine and Technology

Medical advances are leading to decreased sequelae after initial trauma/insult; e.g., sequelae of neurologic deficits following stroke are declining.
Surgical, pharmacological, and prosthetic interventions are reducing and replacing the need for behavioral therapy; (e.g., laryngeal surgery, tracheoesophageal prosthesis, Mestinon, thymectomy.)

4. Culturally Diverse Population

A more culturally diverse patient population is requiring providers to establish cultural competency by having improved knowledge of different cultural perspectives on health care and placing value on cultural differences.

5. Societal Expectations of Purchased Services/Consumer Awareness

Internet access is providing health care consumers with information regarding choices of providers, services, procedures, etc.
Consumers expect measurable benefits for their health care dollar.
Patients are voicing their wishes and choices regarding health care options.

6. Expanded Facilities for Care of Patients

Efforts to control health care costs have resulted in expansive development of alternative health care models, including hospice, home health care, subacute rehabilitation centers, telepractice, etc. Acute care hospitalization has long been recognized as the most costly health care option. National health care reforms include efforts to reduce acute hospitalization and, once admitted, to shorten patients' lengths of stay.

7. Emphasis on Evidence-Based Practice (EBP)*

Patients, payers, and other medical professionals are more frequently questioning the research supporting various interventions. SLPs, like other professionals, must ensure the provision of services supported by the best available evidence and be aware of the principles of EBP.

Impact on Speech-Language Pathologists

The multiple changes noted above have led to complex effects on how speech-language pathologists carry out their job duties. Among these effects, the only constant has been a state of flux, with clinicians forced to rethink their goals and objectives on an ongoing basis. The effect on speech-language pathologists includes: shifts in patient service delivery, changes in staffing patterns, and role changes. Discussion of the consequences of these changes in health care on the practice of speech-language pathology in the acute care hospital setting follows.

Consequences to Speech-Language Pathologists Working in an Acute Care Hospital Settings

Model of Care

Speech-language pathologists function primarily as consultants in the acute care medical setting. Patients are seen when physicians request or "consult" the speech-language pathologist (physicians' written orders in medical record). The role of the speech--language pathologist is to provide evaluation and differential diagnosis of the communication and/or swallowing disorder, treatment and symptom monitoring, and education and counseling to the patient, family or care provider. Critical in their role as consultant is for the speech-language pathologist to clarify the physician's reason for consulting and to address the question(s) being asked.

1. Consultations are prioritized by physicians to facilitate the patient's safe discharge to the most appropriate setting.

2. Consultations come from many different medical specialists including:

Neurology
Otolaryngology
Pulmonology
Gastroenterology
Pediatrics
Physiatry

Problems and Realities for Clinicians

Reduced referrals: Often requests for speech-language pathology are limited to services that are necessary for the patient to be safely discharged.
Response timeliness: Turn-around-time to respond to consultation requests must be minimized. (Weekend coverage may be required.)
Increased efficiency: A decreased number of hours are allocated by clinicians to each patient's management.
Time management: Effective time management may require seeing more patients for shorter periods of time.
Clinicians are responsible for increased numbers of patients.
Increased productivity: Productivity is defined by the time required to address the total needs of the patient (e.g., direct time with the patient, as well as verbal and written communications with other providers to assure continuity of care).

Impact on Patient Service Delivery

In light of the above factors speech-language pathologists are required to change the way they deliver services. These trends have been observed across the country:

Providing increased consultation rather than traditional rehabilitation services
Collaborating with physicians, nurses, and other members of the patient's health care team
Working with interpreters or providing services in another language (bilingual clinicians)
Providing care through telepractice
Using more technology

Quality of Life Issues

With the increased aging of the population, speech-language pathologists are being called on to assist in patient management with end-of-life issues as part of total patient management. Speech-language pathologists with expertise in dysphagia are often involved in questions regarding a patient's ability to receive nutrition orally or whether alternative-feeding options should be considered. Additionally, the speech-language pathologist has the responsibility for advocating for the patient or assisting the patient in communicating his or her wishes regarding oral feeding. This may occur, for example, with an elderly patient who elects to continue to eat for pleasure despite known aspiration.

Speech-language pathologists are involved in helping patients with communication deficits share their preferences regarding health care decisions. JCAHO standard RI.2.30* states, "Patients are involved in decisions about care, treatment, and services provided." Another standard (RI.2.100) states, "The organization respects the patient's right and need for effective communication." These standards include patients' right to self-determination. The patient has the right to receive care that is considerate and respectful of his or her personal values and beliefs. It is also the patient's right to participate in ethical questions that arise in the course of his or her care. Because of their expertise in communication, speech-language pathologists are participating on bioethics committees and in conducting bioethics consultations

Staffing Patterns

The following trends in staffing patterns have been observed across the country:

Stable or declining FTEs (full time equivalents = 40 hours per week paid staff time)
Flexible schedules (variable schedules based on number of patients and staffing needs)
Specialized staff with broad-based experience (staff with expertise in one or more areas within the scope of practice who are willing and capable of providing cross-coverage to a variety of patient diagnostic categories)
Greater need for generalist skills across a broader scope of professional practice in programs that are downsizing to only one or two staff
Increased cooperation and collaboration among staff within departments or programs
More diverse caseloads, traveling more within the hospital and to satellite clinics
Fewer support staff so that clinicians perform more clerical functions
Supervisors of speech-language pathology who are not speech-language pathologists

Changes in Documentation

Trends in the requirements for documentation that have been observed across the country include the following. Documentation must:

Be more concise and less redundant
Be directed to the question being asked
Address only essential information contributing to patient management and team issues and concerns
Be more automated
Conform to HIPAA standards (for covered entities)

As noted, consequences to speech-language pathologists involve changes in referrals, workload, productivity, type of service delivery, staffing patterns, and documentation. Therefore, it is critical for speech-language pathologists in the acute care setting to understand their role as consultants, which involves "integration of the pieces" and the concept of "patient management" rather than "direct treatment."

Integrating Patient Issues

The speech-language pathologist in this setting is responsible for integrating relevant patient issues and variables into clinical decision making. The following factors must be considered.

Communication and swallowing diagnoses
Etiology and previous medical conditions
Previous functional level and social situation
Severity of deficits
Anticipated length of stay
Discharge plan
Patient support system after discharge
Predisposing factors (e.g., substance abuse, medications, psychiatric history)
Awareness and motivation (i.e., cognitive status)

Patient Management

Patient management involves defining what is critical for the patient to communicate and meet nutritional needs relative to the disease process in this setting at this time. The role of the speech-language pathologist is to manage and contribute to the patient's safe, timely and efficient discharge. The role of the speech-language pathologist as a consultant is to provide a piece of the puzzle in deciphering the differential diagnosis and appropriate patient management.

The Role of the Speech-Language Pathology Consultant

Define the nature and severity of the swallowing problem, determine the prognosis, and address the nutritional needs of the patient.
Provide differential diagnosis of speech and language disorders, determine prognosis, and make recommendations for follow up treatment.
Identify how to manage communication needs in the hospital environment (e.g., using Passy-Muir speaking valves, augmentative communication devices and patient call light).
Advocate for patients when they are making quality of life decisions.
Understand and value cultural differences; (e.g., for dietary choices or food/liquid textures).
Monitor symptoms, impact of management on symptoms, and critical decision making.
Provide education and training for patient and/or family.
Educate other team members (e.g., physician, nurse, respiratory therapist, physical and occupational therapists, dietitian).
Communicate in a timely and effective manner across patient care provider team members.
Know what referrals are appropriate for the patient; e.g., alternative care models, and assisting in discharge planning.
Maintain awareness of the continuum of care available among community resources.
Maintain strong communication links with community resources.
Maintain close communication with surgeons involved in reconstruction of the communication and swallowing mechanism.
Explain to the patient and family the impact of surgical procedures on the patient's ability to communicate or swallow.
Provide increased accountability and measurable outcomes.

When speech-language pathology services are rooted within physical medicine and rehabilitation (PM&R), the scope of services may be expanded by developing relations with other medical disciplines besides PM&R, and by demonstrating competence and value in differential diagnosis and patient management.

Roles and Skills

In the face of these multiple challenges, the speech-language pathologist must be open to changing roles. In some cases, these shifts will include expansion of current roles. Examples of this type of shift may be an increased focus on counseling and training families, intensification or increased proficiency in data collection for outcome information, or increased facility with computers. In other cases, there may be actual changes in job roles, such as assuming roles as case managers, rehabilitation directors, or marketers of services.

The question of scope of practice and job boundaries is increasingly pronounced. As noted, speech-language pathologists may be asked to take on tasks not traditionally performed. A decision on what is ethical and quality practice must be made by each clinician, within the context of the ASHA Code of Ethics and Scope of Practice. Similarly, issues of maintenance of quality of care in the face of multiple external demands force some into decision making about what is and is not acceptable practice.

A critical role for all speech-language pathologists is that of advocate. This need for advocacy cuts across many levels. It may involve advocacy for an individual patient to receive appropriate care. It may also require advocating on the behalf of our credentials and qualifications when faced by competition from another discipline with overlaps in scope of practice. We may need to advocate for reimbursement with a payer. In the larger picture, we must all assume responsibility for advocating for our patients and our profession with state and federal legislators, those who have established the new rules that are rapidly changing how we deliver our invaluable services.

Needed Knowledge Base

It is recommended that speech-language pathologists who provide services in an acute care hospital setting have knowledge of the following:

Difference between treatment and management
Difference between evaluation and differential diagnosis
Health care regulatory agencies, especially those related to hospitals (e.g., Joint Commission, Medicare, state Medicaid programs)
Mission, goals, and initiatives of the institution(s) in which services are provided
Case management
Consultation model in an acute care setting
Continuous quality improvement principles and process
Marketing strategies
Outcome measures (ASHA NOMS, FIM)
Costs of services
Charging and billing practices
Documentation practices required by payers
HIPAA regulations
Biomedical ethics and related hospital policies and practices
Interests, skills, competencies of other hospital-based health care professionals
Competencies, skills and interests of physicians within hospital and associated clinics
How to review, critique and incorporate research into clinical practice
How the speech-language pathology differential diagnosis contributes to medical diagnosis
Understand and value different cultural differences in health care delivery
Communication and teaching skills for interacting with physicians and other health care providers
How to prioritize patient needs
How to pursue and access continuing education opportunities through creative planning
Cross-covering within the profession, practicing as a generalist
Specialization in one or more aspects of professional scope
How to access information through online literature searches, internet resources, library specialists
OSHA Regulations
ASHA Code of Ethics
Time Management

Resources/References

American Medical Association. (2005). Physicians' current procedural terminology . Chicago, IL.

American Speech-Language-Hearing Association. (1996). Curriculum guide to managed care . Rockville, MD.

Balanced Budget Act , Pub. L. No. 105-33 (1997).

Flower, R. M. (1984). Coding systems for clinical information. In Delivery of Speech-Language Pathology and Audiology Services (pp. 174-194). Williams & Wilkins. Baltimore, MD.

ICD-9 International Classification of Diseases

Johnson, A. (1999, March). Managing or Caring? ASHA Special Interest Division 2, Neurophysiology and Neurogenic Speech and Language Disorders Newsletter 9, (1) 6-8.

Johnson, A.F.& Jacobson, B. H. (eds.). (1998). Medical speech-language pathology: Practitioner's guide . New York: Thieme Medical.

Joint Commission on Accreditation of Healthcare Organizations. (2004). Comprehensive accreditation manual for hospitals . Oakbrook Terrace, IL.

Definition of Terms

Balanced Budget Act of 1997: Law designed to bring U.S. budget into alignment; significantly affected models of payment and delivery of therapy services, including a new PPS (see reference) model for skilled nursing facility.
Capitation: A fixed amount ("cap") which is paid per enrollee of a health plan to the provider regardless of actual costs. Providers then decide how this amount will be spent, i.e., who will receive services, what services will be rendered, frequency, and duration of services, etc.
CARF: (The Rehabilitation Accreditation Commission). Organization that provides voluntary accreditation to various rehabilitation facilities, including hospitals, free-standing units, behavioral health care facilities.
Case Managers: Individual charged with coordinating and monitoring care delivered to patients, with goal of achieving desired outcome within cost constraints. Typically, case managers may be nurses, ancillary health professionals, or individuals specifically trained in case management.
Centers for Medicare and Medicaid Services (CMS): The federal agency responsible for overseeing and administering the Medicare and Medicaid programs.*
Clinical Pathways (critical pathways): A "map" of preferred interventions. Includes timing of initiation of services and length of treatment for various providers; developed around a specific disability (e.g., stroke). Offers a means to monitor outcomes and costs of care and reduce clinical variability.
CPT Codes: Current procedure terminology codes. Standardized mechanisms of reporting services using numeric codes established by the AMA. Codes consist of 5 digits and are used in coding of patient services delivered for billing purposes.
Deemed Status: Status conferred by CMS (see listing) when a health care institution is determined to be in compliance with relevant Medicare conditions of participation through voluntary accreditation through an entity (such as JCAHO) whose standards and survey process are equivalent to those of Medicare.
Disabilities: See impairment.
Discounted Fee-for-Service: A negotiated, reduced fee that is paid to providers, typically after services are rendered.
DRGs or Diagnostic Related Groups: An inpatient or hospital classification system used to pay for hospital stays for specific diagnoses (e.g., head injury). One lump sum is paid the institution to cover all costs of care. The hospital then determines length of stay, services delivered, etc.
Episodic Care: Care delivered by "episode"-defined as a spell of illness, single occurrence of a disability or otherwise.
Evidence-based Practice: Clinical practice based on the integration of: (a) clinical expertise, (b) best current evidence, and (c) client values to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve.*
Fee-for-service: A reimbursement model under which a usual and customary fee is paid to the provider after services are rendered.
ICD-9: International Classification of Diseases. A universal coding method used to document the incidence of disease, injury, mortality, and illness. A diagnosis and procedure classification system designed to facilitate ease and uniformity of data collection. Used to group patients into DRGs, prepare billings, and prepare cost reports.
Impairment: Underlying anatomic, physiologic or disease state which may lead to functional difficulties and handicapping conditions. Example - impairment: stroke; functional problem: expressive language disturbance; handicap: difficulties in social interactions. New terminology: impairment, activity, participation (World Health Organization).
Levels of Assistance: Range of care levels needed and/or provided in long term care facilities and other settings.
Long Term Care: A set of services (medical, rehabilitation, personal care) for people who have lost a degree of functional capacity. May be used narrowly to refer to institutions providing care to these people (e.g., skilled nursing facilities).
Managed Care Model: Model of payment and service delivery based on a capitated (see reference) or discounted fee-for-service arrangement. Designed to integrate cost containment into delivery of care.
Minimum Data Set: Assessment and referral tool used in skilled nursing facilities to assist in delivery of individualized, appropriate care. Used to derive Resource Utilization Groups (see reference) under PPS in skilled nursing facilities.
Multiskilling: Cross-training of skills. ASHA endorses cross-training or multiskilling of basic patient skills, professional non-technical skills and administrative skills, but not of professional clinical skills (see ASHA 1997 position statement and technical report).
OASIS: "Outcome and Assessment Information Set"-tool used to collect data on home care patients, as mandated by and reported to CMS. Data to be used for case- mix adjustment and outcome based quality improvement.
Patient Care Coordinator: Individual assigned to a patient to coordinate various aspects of care within available reimbursement parameters.
Per Beneficiary Limit: "Therapy cap"-Limitation on cost of Medicare Part B services allowed to be reimbursed for each individual (beneficiary) receiving therapy services.
Per Diem: Reimbursement payment on a daily basis; typically all-inclusive fee.
PRN: Employment on an "as needed" basis.
Product-line Model: A set of services or goods that can be used by or that is experienced by the patient that can be viewed and used as a product measure.
Prospective Payment System (PPS): Payment system that establishes rates before services are rendered. PPS is currently in place in most health care settings, including acute care hospitals, inpatient rehabilitation hospitals, skilled nursing facilities, and home care.*
Provider Networks: An affiliation of providers developed through either formal or informal contracts and agreements. Develops a list for referrals of providers within the network; may contract externally for administrative and financial services to lower joint overhead.
Resource Utilization Group (RUG) Categories: Reimbursement categories used under the PPS (see reference) for skilled nursing homes. Each category determines amount of therapy received. RUG category is derived from the MPS and determines per them payment level.
Subacute Care: Care rendered after acute hospitalization. May be restricted to immediate period after discharge for high medical complexity and rehabilitation intensity patients; or may be used for entire spectrum of care, e.g., skilled nursing care, home care.
Uncompensated Care: Services rendered that are not reimbursed through insurance or patient private pay.
Universal Precautions: A set of precautions designed to prevent transmission of human bloodborne pathogens, such as HIV or Hepatitis B virus when providing health care.

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