Day 4 in Home Health
Day 4 is Thursday. I don’t have to work the weekends unless I want to work a Saturday or Sunday. The great part of my job is that although I’m the only SLP for our area (job security!) I have a lot of flexibility! I can schedule myself Tuesday through Saturday or Sunday through Thursday if I want to take off some time through the week and not use PTO.
I mentioned in previous posts that we have to take vitals for every patient. There is a required section in our paperwork where we put in the patient’s vitals and we have a vital log in the home that we complete every visit so that the patient has a recorded list of their vitals.
We take blood pressure, temperature, respiratory rate and pulse. We can check oxygen levels if there is a doctors order in the chart.
I start my Thursday at 9 about 25 minutes from my own house. This is a patient in their early 90’s and has been on my caseload before. She was having difficulty with swallowing our first round of therapy, especially when drinking from a straw. Patient and family both declined instrumental testing so we did the best we could at that time and worked on drink size and took away the straw which seemed to help. I know, instrumental would have been preferred, but it was not an option even after much education. I am now seeing the patient because the family feels she needs a “tune up”. She has also resumed use of straws which is more than likely contributing to the problem. Part of this will be trying to find an acceptable cup that works for the patient and eliminates choking.
My next patient is across town and in her later 90’s. She was put on a mechanical soft diet and honey thick liquids at her most recent MBSS so we’re working on timing and coordination of the swallow. This patient also has COPD and reminds me every session that she was never even a smoker!! This patient loves to talk and tell stories so we have some talking time while I’m taking vitals and entering some of the physical information in my tablet and then we work. We have worked on nectar thick trials and a bolus hold and effortful swallow. I have Simply Thick packets of thickener in my bag and just use water or whatever the patient has in her refrigerator for the trials. I also keep a Simply Thick shaker bottle with me that I wash at the patient’s home (sometimes) or put in a bag to wash later when we are done.
I then drive down the road to reassess a patient in their new certification period. Every certification period is 60 days. When that period is over, we either recertify the patient or discharge. When there is a new certification, each discipline also has a new evaluation. This is a patient that is in his 50’s and lives with his parent. There is much concern over a very large weight loss and refusal to eat. There is also refusal to leave the home, eliminating instrumental assessment. There is no obvious physiological reason to have a dysphagia except that the patient has not been eating for some time and drinks a very small amount during the day. I’m talking, maybe 8 ounces per day. There is also refusal to take medication and brush teeth. I get to have that difficult talk with the parent and patient that I just don’t think I can help at this time. There is so much more that needs to be addressed prior to any initiation of treatment. Patient and parent both were in agreement with this.
My next patient had just reached a very important age milestone and was on nectar thick liquids due to pneumonia during their hospitalization. When this milestone was reached, the family stopped using thickener for the patient and patient started refusing therapy so today will be our discharge. Patient was on a free water protocol prior to disuse of thickener with no respiratory issues. At discharge I always leave written instructions of what needs to be completed or symptoms for which to watch in case of need for resumption of therapy. This patient is being discharged and will be admitted to our hospice services.
Typically on Thursdays, I would have another patient nearby that is also working to upgrade liquids. We have already upgraded liquids from honey thick to nectar thick. Patient completes a HEP with trials completed at home with food and liquids working on coordination of the swallow. Patient also completes CTAR (Chin Tuck Against Resistance) exercises and JOAR (Jaw Opening Against Resistance) exercises with me using the ISO device. Patient has also had an overall improvement with strength and function. He is very motivated to work which is great! Which is also sometimes very hard to find in patients!
My next patient is about a 40 minute drive. This patient was diagnosed several years ago with Parkinson’s disease and then about a year ago with Multiple Systems Atrophy, which is a faster progressive degenerative disease than Parkinson’s. We have been working a lot on intelligibility, louder volume, shorter phrases and energy conservation. We have also made some changes with liquids and started using straws rather than a cup as it is easier for the patient to drink this way with decreased choking. Today, I’m acting more as a nurse as the patient has a rash all over, swollen tongue, lips and ears and increased leaning while sitting on the couch. I have to talk to the patient and caregiver and discover the patient had some medication changes recently and was placed on an antibiotic at that time. Family is wanting to give Benadryl, but after taking vitals and several phone calls, we get the patient an appointment at her physician’s office.
My last patient is another 25 minute drive. This patient had a diagnosis of aspiration pneumonia with a history of Parkinson’s disease, COPD and previous tonsil cancer. This patient is on a regular consistency diet with nectar thick liquids, which he hates. We worked using NMES (only on the submental region) in conjunction with swallows of a variety of bolus types using an effortful and fast swallow, CTAR and JOAR using the ISO device. This patient also has a home exercise program and is working on strength, coordination and timing of the swallow. This patient is also very happy to have been upgraded back to thin liquids following recent MBSS and is going to be discharged from speech therapy next week.
Work Day is Over
My day is over and I go back to my car, put my hours into UltiPro and head home to make dinner, take my daughter to singing lessons, do laundry, dishes and prepare for Friday. You know, relax.