A Week As a Home Health SLP Part 2

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food

Here it is.  Part 2 of my week, or Tuesday as some like to call it.

I did have a question on my previous post, so let me break down a little of the paperwork and the time it takes me to complete it.  We do use HCHB Pointcare so a LOT of the notes, etc are very repetitive making it a little easier to answer.  As the ONLY SLP for our branch of the company, I am responsible for Start of Care for speech only patients which takes me 2-3 hours depending on the patient, Recerts which take me 45-60 minutes, Resumption of Care which I have never had to complete yet (fingers crosse), discipline evaluations which take me 45-60 minutes, reassessment which takes me 45 minutes and daily notes which take approximately 10-15 minutes to write.

Our company expectation is 45 in the home, but there are times that 45 is too long or not long enough.  I see the patient the amount of time they need for that day.

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A Week As a Home Health SLP Part 1

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driving

There have been a lot of blog posts recently looking at a day in the life of an SLP in a variety of settings.

I took a job as a Home Health SLP 1 year and 2 months ago.   In 2013, I was completely burnt out on the medical field and decided to take a job in the school system.  For a change.  I found that I missed the medical side.  I continued in the hospital on a PRN basis and continued medical-based continuing education.  In 2016, I decided to go back to the medical field because I really missed working with adults.

Here’s a look at my previous week in home health which will be written in 5 parts over 5 days:

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My Top Five Continuing Education Courses in Dysphagia

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We all have to do it.  Some of us love it more than others.  Continuing Education.  Since six years of school just wasn’t enough!

I have been through A LOT of continuing education courses.  I’m sure you’re thinking, yea, so have I.  I really honestly do take a lot of courses.  In fact, I’m working on my 12th ACE award.

I will definitely say that I’ve enjoyed some courses and thoroughly detested some courses.  I have walked out of courses, vowed to never listen to certain speakers again and also vowed to see people any opportunity I have.

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We Can’t Treat What We Don’t Know

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Call it what you like, a bedside swallowing evaluation, a bedside swallow, a clinical swallow evaluation. No matter what you call it it’s never the same. At a recent ASHA convention there was a session by Leder, Coyle and McCullough which addressed the clinical swallow evaluation versus instrumental evaluation. Dr. Coyle stated that the bedside evaluation is merely a series of pass and fail screens. You can visit many facilities whether they be hospital skilled nursing acute rehab or home health and rarely will you see two SLP’s complete the clinical bedside evaluation the same.

McCullough also has an interesting article on the ASHA website with various resources titles To See or Not to See.

There are always various views.

“A Modified Barium Swallow Study is just a moment in time.”

“I can assess a patient without an instrumental using palpation, observation and clinical judgment.”

“You can’t accurately assess a patient without doing an instrumental.”

One of the main problems with all of our assessments are they are not standardized, whether it’s a Clinical Exam or Instrumental.

The work of Bonnie Martin Harris has started the standardization process for the Modified Barium Swallow Study through the MBSImP (Modified Barium Swallow Impairment Profile), however not everyone has to take this course to complete the MBSS. Not only does the MBSImP have an aim to standardize the MBSS, it also addresses identifying and reporting functional deficits or physiological impairments rather than commenting on what happens with every consistency.  The goal of the MBSImP is to find impairment through trials of a set of consistencies rather than to identify every consistency which is difficult for the patient.  Martin-Harris, B., Brodsky, M. B., Michel, Y., Castell, D. O., Schleicher, M., Sandidge, J., … & Blair, J. (2008). MBS measurement tool for swallow impairment—MBSImp: establishing a standard. Dysphagia, 23(4), 392-405.

FEES has had tools to help standardize interpretation, including interpretation of the residue amount through the Yale Pharyngeal Residue Scale.   There are numerous courses available to teach the anatomy and physiology of the pharynx as viewed through the endoscope.

The American Speech Language and Hearing Association (ASHA) has given us guidelines for “best practice”.   Within the ASHA Rules of Ethics, it states:  “Individuals shall use every resource, including referral and/or interprofessional collaboration when appropriate, to ensure that quality service is provided.”

ASHA provides us with guidelines for SLPs performing MBSS which you can find here.   There are also guidelines for those performing FEES which you can find here.

So why do we need instrumentation?  What’s the big deal?

There are many areas that we can and cannot view with a Clinical Dysphagia Examination.

You can’t see the epiglottis.  In fact, you can’t see anything in the pharynx.  It’s always difficult to assess movement and physiology of an area you can’t see.  I recently had a patient for an MBSS that told me that during the Clinical Evaluation they were told that their epiglottis is not moving.  During the MBSS, the epiglottis moved just as it should.  You can’t just assume by a symptom such as coughing that it is an airway protection deficit.

You can’t assess bolus flow.  If you have attended the Critical Thinking in Dysphagia Management course you know that assessment is broken down in 2 main areas.  Bolus flow and Airway Protection.  If you haven’t yet attended the CTDM course, it is highly suggested you do!  There is even an online version.   The point is though, once the mouth is closed, you just can’t see where the food or drink is going and how it reaches it’s final destination.

You can’t assess airway protection.  Have you ever assessed a patient at bedside and after palpation of the larynx feel pretty confident that the larynx is moving?  Then you start trying to figure out why the patient has a wet cough later in the day.  You take the patient downstairs for a swallow study and low and behold, there is no laryngeal elevation.  What you felt was the tongue moving trying to initiate a swallow.  Go ahead, put your fingers on your larynx and move your tongue.  What do you feel?

Compensatory Strategies.  My friends Theresa wrote a blog post about compensatory strategies that is definitely worth a look.  How do we know for sure that a compensatory strategy is effective or that the patient is actually able to do the strategy in the correct way?  You might remember a post I wrote earlier about the chin tuck.   There was also a great post on SwallowStudy.com about the chin tuck.


Remember that by not providing our patients with best practice in assessment we may be putting them at higher risk for:

  • dehydration
  • aspiration pneumonia
  • malnutrition
  • increased length of stay
  • re-admission

Our patients deserve the best.  instrumentals aren’t always necessary for all, but they do answer many questions beyond did the person aspirate.

Better Hearing, Speech and Swallowing Month

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Many people ask me what I do. When I say Speech Language Pathologist, I often get a blank stare. I am a Speech Therapist also, but Speech Language Pathologist means that I not only treat, but assess and diagnose.  
I work with a variety of speech, language, voice and swallowing deficits including aphasia, apraxia, cognition, articulation. I do not only work with kids that have trouble saying their sounds, I work with adults to help them regain their swallowing and/or their communication.
My job is not easy. I get attached. I very recently had a patient (head and neck cancer patient with whom I worked 5-6 years ago) passed away, after choking on a piece of meat. Although there’s always that little bit of guilt there, maybe I didn’t do enough, I rest easy because I know I did do everything I could to make their life better. 
This person taught me a lot about becoming a better professional and listening. This person never completely regained their swallowing ability. This person aspirated on their very last swallow study. We knew this was happening. This person had excellent oral care, was very active and knew to take small bites, chew carefully and take their time swallowing. This person functioned for 5 years with no consequence until recently.
Although it is so hard to lose a patient and friend, I’m looking at the bright side of what I gave back to this person. I gave them their independence so they could socialize, vacation, work, meet with friends and family without the burden of a feeding tube.  
I recently saw another former patient of mine who told me the perfect words and I will carry this with me forever…. “You took something that we had that was very bad and you made it good again.”
I am a Speech Language Pathologist and I help people regain their independence, one swallow at a time.

#BHSM #slpeeps #medslp #dysphagia #swallowingmatters #dontforgettheswallow #idomorethanjustspeech

Four Things You May Not Know

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                                                       Knowledge

A couple of weeks ago,  as I was driving around from home to home I stopped at McDonald’s because 1.  I had to use the bathroom and 2.  I really needed something to drink. Seeing my scrubs the cashier asked me if I was a nurse. I said no I’m a speech language pathologist but I’m often called the nurse and drive a nurse car. It was National Nurse’s Day and McDonald’s was giving a free coffee drink to any nurse that came in and showed their badge or some form of ID. I did get a free caramel latte.

It made me think though that we have so many days to honor and appreciate other professionals. We have a month for speech language pathology  that nobody really celebrates but us.

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Standardizing Dysphagia Assessment and Treatment

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Sometimes in our professional career we see, read or hear something that goes against everything we’ve learned where everything we think we know. I recently wrote a blog post about three things we need to stop doing and dysphagia assessment and treatment. That post was a challenge.

Sometimes we have to step out of our comfort zone and realize that what we’re doing needs an upgrade. Research and dysphagia is constantly evolving and showing us what we should and should not be doing.

There is no all or nothing and there is no cookbook recipe to assessing or treating dysphagia. What we need to become competent in is reading the research articles. These articles are not all or nothing. We may have a patient that the Mendelsohn maneuver is a perfect contribution to their therapy program however have 10 other patients for whom the Mendelsohn maneuver is not an option.

Research gives us a guide to help us develop an appropriate program for each patient.

When we sit in the dining room day after day and watch patients eat it downplays our role as a pathologist.  We become an aid or a waitress to many of the patients in the dining room.  Now that’s not to say that there aren’t appropriate times to assess the patient in the dining room.  What better way to assess the patient at mealtime? It is however not a skilled treatment when we sit in the dining room day after day assessing or monitoring patient tolerance.

What we need to do as a profession is to become skilled at prescribing an appropriate therapy program for dysphagia. There is an article by Dr. Gisele Carnaby called usual care and dysphagia therapy that was very eye-opening.  Dr. Carnaby and colleagues found that given one scenario they were provided with over 90 treatment plans and no two treatment plans were the same.

When we keep up with the research and new developments in our field we know that we can begin to standardized our assessment and treatment with programs such as:

  • The Modified Barium Swallow Impairment Profile- A standardized protocol to completing and analyzing the MBSS (modified barium swallow study).
  • The McNeil Dysphagia Therapy Program- A systematic, exercise based therapy program using food as resistance.
  • Pharyngocize- A protocol developed for patients with head and neck cancer.
  • Expiratory Muscle Strength Training- A program developed to increase respiratory muscle strength for increased cough response and swallowing ability.

Let me know your favorite evidence-based protocol.

Carnaby, G. D., & Harenberg, L. (2013). What is “usual care” in dysphagia rehabilitation: A survey of USA dysphagia practice patterns. Dysphagia, 28(4), 567-574.

Martin-Harris, B., Brodsky, M. B., Michel, Y., Castell, D. O., Schleicher, M., Sandidge, J., … & Blair, J. (2008). MBS measurement tool for swallow impairment—MBSImp: establishing a standard. Dysphagia, 23(4), 392-405.

Carnaby-Mann, G. D., & Crary, M. A. (2010). McNeill dysphagia therapy program: a case-control study. Archives of physical medicine and rehabilitation, 91(5), 743-749.

Crary, M. A., Carnaby, G. D., LaGorio, L. A., & Carvajal, P. J. (2012). Functional and physiological outcomes from an exercise-based dysphagia therapy: a pilot investigation of the McNeill Dysphagia Therapy Program. Archives of physical medicine and rehabilitation, 93(7), 1173-1178.

Lan, Y., Ohkubo, M., Berretin-Felix, G., Sia, I., Carnaby-Mann, G. D., & Crary, M. A. (2012). Normalization of temporal aspects of swallowing physiology after the McNeill dysphagia therapy program. Annals of Otology Rhinology and Laryngology-Including Supplements, 121(8), 525.

Carnaby-Mann, G., Crary, M. A., Schmalfuss, I., & Amdur, R. (2012). “Pharyngocise”: randomized controlled trial of preventative exercises to maintain muscle structure and swallowing function during head-and-neck chemoradiotherapy. International Journal of Radiation Oncology* Biology* Physics, 83(1), 210-219.

Kim, J., Davenport, P., & Sapienza, C. (2009). Effect of expiratory muscle strength training on elderly cough function. Archives of gerontology and geriatrics, 48(3), 361-366.

Pitts, T., Bolser, D., Rosenbek, J., Troche, M., Okun, M. S., & Sapienza, C. (2009). Impact of expiratory muscle strength training on voluntary cough and swallow function in Parkinson disease. Chest Journal, 135(5), 1301-1308.

Kim, J., & Sapienza, C. M. (2005). Implications of expiratory muscle strength training for rehabilitation of the elderly: Tutorial. Journal of rehabilitation research and development, 42(2), 211.