Getting Started in Long-Term Care

This specialized community may also be called a nursing home, geriatric care facility or long-term care facility. People don't tend to think of long-term care residents as an ever-changing population. However, the skilled clinician in this setting learns quickly that the residents are on a continuum of change. Their needs, while appropriate this week, may need modification in the blink of an eye with illness, injury, or change in mental status. When residents improve and re-gain skills that were lost, they rely on the SLP to re-work their therapy goals and continue to direct them toward recovery. Working within this setting can be very stimulating to the speech-language pathologist that loves the challenge of problem-solving, recognizes the benefits of interdisciplinary evaluation and planning, and appreciates the rewards of seeing a resident return to a higher level of function or stabilizing after a decline in health.

Patient Demographics

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

Age range of patients in long-term care

• 60-69 years: 10%
• 70-79 years: 27%
• 80 years and older: 58%

Top 5 primary medical diagnoses of long-term care residents

• CVA: 25%
• Mental disorders: 13%
• Respiratory diseases: 12%
• CNS diseases: 10%
• Other neoplasm: 2%

Top 5 Functional Communication Measures scored by SLPs working in long-term care

• Swallowing: 72%
• Memory: 27%
• Problem-solving: 20%
• Spoken Language Expression: 20%
• Spoken Language Comprehension 19%

Average length of stay for long-term care residents

35 days

Reimbursement mechanism

Medicare Part A

Under the Prospective Payment System (PPS) for Skilled Nursing Facilities, speech services are part of a daily rate depending on the resident's payment group, as determined by completion of the Minimum Data Set (MDS). The minimum number of rehabilitation minutes (including occupational therapy, physical therapy, and speech-language pathology) that the resident must receive is based on their payment group assignment.

For additional information:

Medicare Prospective Payment System: A Summary

Medicare Part B

This Medicare program pays for services for the resident on an outpatient basis after Part A benefits are exhausted. Payment for these services are based on a fee schedule tied to CPT Codes (Current Procedural Terminology). These are codes that describe evaluations and interventions delivered to a patient when receiving speech and language services.

In 1999, therapy caps went into effect that applied a limit to the amount of money spent on rehabilitation services for each episode of care per beneficiary (resident). One cap applies to occupational therapy services and a cap of equal amount applies to both physical therapy and speech-language pathology services combined. An exceptions process was implemented in 2006 that allows for billing to exceed the cap if documentation supports the need for such an exception. Congress continues to consider alternatives to the cap and ASHA is contributing to this discussion through lobbying efforts.

Reimbursement is also available for long-term care residents enrolled in some state Medicaid programs, private insurance plans or managed care plans. Each plan pays according to the conditions of their individual coverage and payment guidelines.

Referral Process

There are three main ways to initiate referrals for speech-language pathology services:

1. Physician orders for SLP evaluation and treatment upon admission to the long-term care facility. This is generally for acute conditions, such as recent onset of dysphagia, that were noted during a hospitalization.
   
2. Identification of residents during a screening. Screening is a non-billable service, and is generally consists of chart review, interview of staff and family, and brief observation of the resident. Screenings are generally conducted upon admission, upon specific referral of staff or family, and periodically to coincide with the facility's care plan schedule.
   
3. Staff/family referrals. In order to facilitate accurate referrals, the speech language pathologist must continually educate family members, other rehabilitation professionals, facility staff, physicians, and discharge planners regarding the variety of services they provide.

Collaboration with other disciplines

To be successful in the long-term care setting, you must work effectively within an interdisciplinary team. You will find numerous opportunities to work with physical therapists, occupational therapists, recreation therapists, nurses, social workers, dietitians, and others who provide care to the residents of your facility. The relationships you establish will determine in no small measure your effectiveness within this setting.

Long-term care documentation requirements

Although documentation requirements vary according to the payer, typically they must include a physician's order*, followed by a certification for the therapy plan that should include medical diagnosis, SLP diagnosis and treatment plan, and frequency and duration of treatment. Therapy goals must be medically necessary and functional. Subsequently, a "re-certification" form must be filled out and signed and dated by the physician at a maximum of every 90 days. Progress notes are typically written every 7 days.

For Medicare A patients, the actual number of minutes during which the patient receives treatment must be documented. This form documents CPT codes and therapy occurrences.

For Medicare Part B patients, the therapist documents CPT codes and occurrences, as the facility will get reimbursed according to the established rate for each CPT codes, as set by CMS. The utilization of these codes must be supported in the daily/weekly progress notes.

Additional documentation in long-term care includes the Minimum Data Set (MDS), an interdisciplinary tool that paints a picture of the patient's status. Nurses typically complete the MDS, but SLPs may contribute information relative to communication and swallowing.

* Changes to the Medicare Benefit Policy Manual in 2005 eliminated the requirement for a physician's order for outpatient services (Part B). What is required is the physician certification of the plan of care. Other payers may still require a physician order.

Resources

Go to SLP Health Care area 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 ASHA's Web site to access:

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

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

Centers for Medicare and Medicaid Services (CMS)

Minimum Data Set (MDS)