Getting Started in Acute Care Hospitals

Patients admitted into acute care hospitals present with complex medical issues. Typically, only the most critically ill patients remain in the hospital for more than a few days. The speech-language pathologist working in this setting must have a grasp of medical terminology and procedures and the roles of medical specialists and other health care professionals. Speech-language pathologists in this setting provide evaluation and treatment of swallowing disorders and speech and language problems resulting from strokes, head injury, respiratory issues, and other medical complications. SLPs are usually expected to be competent in dysphagia management, including conducting and interpreting videofluoroscopic examinations. Patients typically are seen soon after admission, particularly for swallowing issues, and require daily individual treatment. While some patients are able to tolerate longer sessions, some may only be seen for brief periods of time or more than once per day for short periods, as tolerated. Weekend SLP services for new admissions or seriously involved patients are often provided.

Patient Demographics

The following information comes from the National Outcomes Measurement System (NOMS) data collected by ASHA members across the country.

Age range of acute care patients

• 30-49 years: 11%
• 50-59 years: 11%
• 60-69 years: 17%
• 70-79 years: 27%
• 80 years and older: 30%

Top 5 primary medical diagnoses of acute care patients

• CVA: 35%
• Respiratory diseases: 13%
• Head injury: 6%
• Hemorrhage/Injury: 5%
• CNS diseases: 4%

Top 5 Functional Communication Measures scored by SLPs working in acute care hospitals

• Swallowing: 77%
• Spoken Language Comprehension: 24%
• Spoken Language Expression: 23%
• Motor Speech: 19%
• Memory: 13%

Average length of stay for acute care patients

11 days

Reimbursement Mechanism

Medicare reimburses hospitals based on the patient's Diagnostic Related Group or DRG. Under the DRG system, the hospital is reimbursed a lump sum based on the patient's diagnosis. If the hospital provides more services or the patient's stay is longer than expected, the hospital stands to lose money. Conversely, if the patient's stay is shorter than expected, the hospital receives the same amount of money and stands to come out ahead. Exceptions to this DRG system are some private payers, who may negotiate a rate with the hospital, uninsured patients, and "self pay" patients who pay 100% of charges out of pocket.

Impact of reimbursement system on clinician

Typically, SLP services are not directly reimbursed, but are covered in the DRG allotment. The DRG system has had the effect of hospitals discharging patients to other facilities, such as rehabilitation hospitals or skilled nursing facilities, more quickly, resulting in less time for the SLP to provide services and fewer referrals for specialty services. The SLP caseload may vary, depending on admission rates.

Referral process

The patient's physician typically initiates swallowing and/or communication evaluations and treatment through a referral or "consult". Many medical specialists may be involved in a patient's care and referrals may come from any of these physicians. Some facilities will have established "critical pathways" based on admitting diagnosis that may facilitate the referral process. For example, a critical pathway for an individual admitted with a stroke may include an SLP consult within the first 24 hours for a swallowing evaluation. In this case, the consult is automatically entered into the system upon initiation of the pathway.

Collaboration with other disciplines

Speech-language pathologists collaborate with many professionals within the hospital system, including physicians, nurses, other rehabilitation providers, dietitians, social workers, and case managers. The role of the SLP may be more consultative in nature in this setting than in any other, and the focus is more on patient management than direct treatment. The case manager is a vital part of the patient care team and the SLP may have frequent discussions with the case manager as discharge plans are developed.

Documentation requirements

Documentation is maintained in the patient's chart, if in hard copy, which remains on the floor where the patient is located (or travels with the patient for special procedures). Many facilities are becoming more automated and there is a trend towards "paperless" charts or electronic medical records. Documentation requirements vary by facility, but the SLP in an acute care hospital setting must be able to write concise reports or SOAP notes (Subjective, Objective, Assessment, Plan) that address only essential patient information for appropriate patient management.

Resources

Go to the SLP Health Care section of ASHA's Web site to access:

• ASHA Speech-Language Pathology Health Care Survey
• Health care frequently asked questions (FAQs)
• ASHA member forums
• Issue briefs

Go to the Billing and Reimbursement section of the ASHA Web site to access:

• Billing and coding information
• Reimbursement frequently asked questions (FAQs)
• Medicare Fee Schedule
• Medicare Medical Review Guidelines

Go to ASHA Practice Policy to access documents on preferred practice patterns, dysphagia, clinical record keeping, autonomy, etc.