Guest Columns

The skilled eye of a speech pathologist

Renee Kinder
Renee Kinder

The Medicare Benefit Policy Manual provides guidance for rehabilitation professionals on criteria for reasonable and necessary skilled services which include:

  • Following Evidenced Based Practice Patterns:

Services shall be considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition.

  • Providing Services at a Level of Complexity and Sophistication:

The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a qualified therapist.

  • Not Making Determinations on Diagnosis Alone:

While a beneficiary's particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiary's diagnosis or prognosis should never be the sole factor in deciding that a service is or is not skilled

  • Providing Services at an Appropriate Frequency and Duration:

There must be an expectation that the patient's condition will improve significantly in a reasonable (and generally predictable) period of time and

The amount, frequency, and duration of the services must be reasonable under accepted standards of practice.

Referrals for initiating therapy services often begin when members of the interdisciplinary team (IDT) notice a functional change in an individual. However, providing necessary referrals starts with having an adequate understand of each therapy disciplines scope of practice.  

Today's blog is the first in a series which will aim to improve knowledge base related to scope of practice for physical, occupational and speech therapy services and increase awareness regarding clinical decision making that clinicians use when making determinations related to skilled needs.

DYSPHAGIA SERVICES PROVIDED BY SPEECH PATHOLOGY

It's Monday morning at Sunny Valley Skilled Nursing Facility. Mrs. Miller's nursing aide arrives to serve her breakfast tray of oatmeal, fresh coffee and assorted fruit; however to the aide's surprise Mrs. Miller pushed the tray aside. 

"Not this morning dear. I will just have my coffee and a cup of yogurt." 

The trend continues during noon and supper meals for another week and Mrs. Miller is becoming more selective about foods which she will accept. Nursing reaches out to dietary staff who meets with Mrs. Miller to re-assess preferences, however limited information is obtained as she often becomes short of breath during conversation secondary to diagnosis of COPD. Monthly weights which follow reveal she presents with a significant weight loss of 7% in a 30-day lookback and concerns are expressed during a care plan meeting with Mrs. Miller, her daughter, and members of the interdisciplinary team. The director of rehabilitation suggests a speech pathology consult to assess swallow function.

 "I swallow just fine," reports Mrs. Miller. The daughter agrees, saying her mother has always been a picky eater.

Let's examine why a speech pathology consult was recommended.

To begin, how does Medicare define dysphagia (difficulty swallowing)?

Per the Medicare Benefit Policy Manual: Dysphagia, or difficulty in swallowing, can cause food to enter the airway, resulting in coughing, choking, pulmonary problems, aspiration or inadequate nutrition and hydration with resultant weight loss, failure to thrive, pneumonia and death.

Most often due to complex neurological and/or structural impairments including head and neck trauma, cerebrovascular accident, neuromuscular degenerative diseases, head and neck cancer, dementias, and encephalopathies. For these reasons, it is important that only qualified professionals with specific training and experience in this disorder provide evaluation and treatment. (MBPM,  2015).

Secondly, what does an assessment of swallow include?

Swallowing assessment and rehabilitation are highly specialized services. The professional rendering care must have education, experience and demonstrated competencies.

Competencies include but are not limited to: identifying abnormal upper aerodigestive tract structure and function; conducting an oral, pharyngeal, laryngeal and respiratory function examination as it relates to the functional assessment of swallowing; recommending methods of oral intake and risk precautions; and developing a treatment plan employing appropriate compensations and therapy techniques (MBPM, 2015).

Mrs. Miller's bedside swallowing evaluation

The speech language pathologist meets with Mrs. Miller and her daughter the day following her care plan to assess swallow function with noon meal. Prior to PO intake a thorough oral peripheral exam is completed to assess strength and range of motion of oral and pharyngeal structures.

She is noted to present with the following:

  • Mildly reduced lingual (tongue) ROM limiting her ability to fully move her tongue to each side of her mouth which is necessary during meals in order to clear food residue which often pockets in the lateral sulci (space between our teeth and our cheeks) and

  • Limited rise of the base of her tongue which is an essential area for beginning the pharyngeal phase of the swallow during which is the airway is closed off to allow food to clear into the esophagus while protecting the airway.

Her noon meal tray arrives and of initial concern Mrs. Miller is noted to become significantly short of breath following her first few swallows of liquid. The Borg Rating of Perceived Exertion Scale revealed increased exertion as the meal progressed.

Research in the area of dysphagia has revealed the presence of COPD is most significant risk factor for aspiration pneumonia in nursing home patients. Additionally, there is a small period of apnea (breathing stops) during the pharyngeal swallow which contributes to difficulty for individuals with respiratory compromise and can often lead to increased risks for aspiration as meals progress.

Following completion of the swallowing assessment the SLP is able to analyze all of the essential data to develop a skilled treatment plan of care aimed at improving swallow function while also promoting least restrictive and adequate PO intake to meet nutritional needs and prevent further significant weight loss.

Treatment for dysphagia, per Medicare guidelines, and when following all criteria necessary for reasonable and necessary services, may include the following:

  • Education for patients and caregivers for  training in feeding/swallowing techniques
  • Analyzing amount of intake per swallow
  • Determining appropriate diet texture and liquid viscosity
  • Means of facilitating the swallow and facilitation of more normal tone or oral facilitation techniques
  • Developing feeding techniques and need for self-help eating/feeding devices
  • Providing laryngeal elevation training and oral sensitivity training
  • Establishing and providing training for compensatory swallow techniques
  • Developing techniques to reduce shortness of breath and fatigue during duration of meals

Renee Kinder, M.S. CCC-SLP RAC-CT, is a clinical Specialist at Evergreen Rehabilitation in Louisville, KY. She also serves as Editor for Perspectives on Gerontology a publication of the American Speech Language Hearing Association.

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