Here it is. Day 2 of my week in Home Health, or Tuesday as some like to call it.
Questions on Documentation
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 crossed), 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.
In Home Expectation
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.
Starting the Day
My Tuesdays start out a bit different than other days. I typically start my day at our 25 bed critical access hospital. I go in and do any lingering acute care evaluations and outpatient/inpatient Modified Barium Swallow Studies (MBSS).
Today, I had an outpatient scheduled and an inpatient scheduled for MBSS. Plus there is an evaluation on the acute floor.
First thing, one of the x-ray techs comes to get me. They want me to come to MRI to see the inpatient with the order for MBSS. This patient is highly confused, grabbing everyone, unable to follow commands and agitated. The radiologist and I make the decision to hold the MBSS at this time as it really is not safe for this patient on this day.
The outpatient arrives after being stuck in registration for some time. After waiting for registration and the radiologist to come in, the 8:30 MBSS is now being seen at 10:00. The study goes fairly well and another diet is able to upgrade with a few strategies put into place. This patient wants to make sure that I send the report as soon as I possibly can, which I am more than happy to do.
I have to leave the hospital before I am completely done, so I write the report and then head out to see my home health patients. I will just have to get the evaluation done after home health.
I drive about 20 minutes to see my first patient. This is a person that was hospitalized for aspiration pneumonia and placed on nectar thick liquids. We have finally upgraded to thin liquids and are continuing to work on strength and timing to ensure that he is safe with his current diet level. We do several things during our time. We use the McNeill Dysphagia Therapy Program (MDTP), Chin Tuck Against Resistance (CTAR) using the ISO device and Jaw Opening Against Resistance (JOAR) again using the ISO device. We work on hard and fast swallows and not gulping water.
My next patient lives about 15 minutes away and is an aphasic patient. We are working on fluent speech in sentences. She loves using the iPad for speech and absolutely loves the Tactus Therapy app for apraxia. This app allows her repetition of commonly used phrases and sentences with faded cues. She like it also because I’m not nagging her with her speech, although I am helping with cues and providing feedback or assistance as needed. We work for a solid 45 minutes with some rest breaks in there. Who says speech can’t be hard work?
I read the notes for my next patient and see that he has been in the hospital, so I mark him off of my list for this week. We’ve been monitoring blood pressure and it looks as though hypertension has got him again.
Next on the List
My next patient is another dysphagia patient. This person was unable to swallow due to a “growth in the larynx” that has resolved. We figured out at the evaluation that I was the one who completed her most recent MBSS. There was minimal weakness with some laryngeal penetration. This person was finally able to eat and drink following that MBSS after some time of NPO status. This visit seems to be a bit more on the nursing side though. She had a fall over the weekend and had to get stitches in her knee which requires a call to the doctor. She is also out of medication and unsure of how to get the refills. Some days I do a lot of “nursing” type work. After all that, we finally started a home exercise program, upgraded to thin liquids and regular consistency food. She has been cheating at home, is medically stable and has had no compromise with the cheats. We make sure and establish a solid oral care program to be completed at home and will stop all thickener at this time. These are seriously the sessions I live for!
My next patient cancelled. This is a total laryngectomy patient that is having esophageal dilatation. FINALLY! We have been waiting weeks for this, after we waited weeks for an order for MBSS. We’re still waiting for the TEP to be placed. I’m sure we will continue to wait……
Last but Not Least
My last home care patient is another dysphagia patient. This is a patient that is relatively young. Posture is very poor with probably damage to the esophagus causing digestive issues and sensation of globus. Much of this session is teaching the patient and family about the esophagus and how posture can affect the digestive tract. This will take a lot of education and teaching. Next week will be our last session as there is really no more I can do for this patient.
Back to Finish Paperwork
I head back to the hospital to finish that inpatient evaluation. This is a person in the ICU following CVA. The patient is talking and following directions and is able to eat soft foods and drink liquids with no apparent difficulty. I recommend a mechanical soft diet, due to overall fatigue and thin liquids. This patient is not appropriate for an instrumental at this time. While I always recommend MBSS (we don’t have FEES….yet) some patients are unable to tolerate the test or just not appropriate to participate and the recommendation to hold the test has to be made at times. Some patients have no apparent issues, no history that suggests dysphagia and therefore do not require instrumental assessment.
That was a long day and I’m heading home to take care of my family! I’ll see you tomorrow for our Wednesday full of treatment!