A Week As a Home Health SLP Part 4

exercise

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 wasn’t a fan of having to take vitals initially, however I have used that knowledge and the numbers to send 2 patients to the ER.   One of whom ended up with a trach due to respiratory distress.  It is very important to assess the patient overall prior to any treatment.

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A Week As A Home Health SLP Part 3

tablet

I have to admit, being a home health SLP is the first job I’ve had that I’ve had to take vitals for my patients.  Every clinician for our company is required to take blood pressure, temperature, respiratory rate and pulse.

At first I wasn’t too keen on having to take vitals.  I’m not a nurse nor am I a doctor.  After sending my first 2 patients to the hospital, I realized the importance of vitals and even though they do take some of my treatment time, I know they are important for patient care.

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A Week As a Home Health SLP Part 2

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

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


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

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


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