Author: Ainsley Martin, MS, CCC-SLP Edited by: Heather Bolan, MA, CCC-SLP
Book Details
Title: Medical Setting Considerations for the Speech-Language Pathologist
Authors: Kristie A. Spencer and Jacqueline Daniels
Publisher: Plural Publishing Copyright: 2020
Cost: $69.95, https://www.pluralpublishing.com/publications/medical-setting-considerations-for-the-speech-language-pathologist
Chapters/Pages: 5 chapters, 154 pages
Subject: An overview of the role and responsibilities of SLPs in various medical settings.
Applicable Patients/Disorders: Any patient with which a medical SLP may come into contact in any medical setting. This includes, but is not limited to, developmental disorders, neurodegenerative disorders, brain injury, head and neck cancer, psychiatric disorders, cardiac and pulmonary disorders, and encephalopathy.
Content: The chapters in this book detail information specific to the medical SLP including an introduction to members of the medical team, an overview of billing and accreditation, considerations for patient populations as well as common deficits in cognition, speech, language, and swallowing within these various populations, guides for greater understanding of neuroimaging, the effects of medication on cognitive, communicative, and swallowing domains, and infection control measures. Case studies are also presented at the end of the chapters to illustrate real-life applications of the information detailed.
Chapter 1. The Medical Environment: Team Members and Organizational Issues
Medical Speech-Language Pathologists (med SLPs) work in a wide variety of settings including skilled-nursing facilities (SNFs), home health (HH), acute care, inpatient rehab, long term acute care hospitals (LTACHs), outpatient clinics, and intensive care units (ICUs). Despite these different settings, the primary roles of the SLP remain the same: assessment and treatment of cognitive, communication, voice, and swallowing disorders, collaborating with other team members, counseling patients and family members, screening to identify those who may require SLP services, and working to maintain or enhance function while preventing further decline. Team members with which the med SLP may interact include physicians (of varying specialties), nurses, registered dietitians, other rehabilitation professionals such as physical therapists/assistants and occupational therapists/assistants, respiratory therapists, and therapeutic recreation professionals. Each team member holds a different piece of the puzzle and collaboration between disciplines is helpful in seeing the bigger picture when treating a patient. The roles and responsibilities of other team members, as well as the med SLP, are reviewed in this section.
The healthcare environment is one that is also ever-changing. From reimbursement to various accreditations available for different environments (e.g., the Commission on Accreditation of Rehabilitation Facilities) to coding and documentation, the med SLP must have at least a general understanding and be informed of changing policies. For example, in SNFs, reimbursement from Medicare changed from the Resource Utilization Group (RUG- IV) in which reimbursement was based on the number of therapy minutes provided to the Patient-Driven Payment Model (PDPM) in which reimbursement is no longer dependent upon the volume of therapy. While theoretically, nothing should change as the patients who required rehab services under RUG-IV still require the same services under PDPM, many rehabilitation professionals have been laid off, are experiencing unethical productivity requirements, and are being forced to do concurrent or group therapy. The Patient-Driven Groupings Model (PDGM) is the reimbursement system for HH which went into effect in 2020. However, these are topics for another day.
One thing that will remain constant in medical settings is the need to document skilled therapy. This includes utilizing the correct International Classification of Diseases (ICD) code and billing the appropriate Current Procedural Terminology Code (CPT). For example, a person with oropharyngeal dysphagia would have the ICD-10 code R13.12 and a session of dysphagia therapy would be billed under the CPT code 92526. Skilled therapy is defined as; 1. services directly related to a care plan signed by a physician following an evaluation by a therapist, 2. requiring the skills of a therapist (e.g., the treatment cannot be carried out by an unskilled professional), 3. there must be an expectation of reasonable improvement or prevention of further decline, 4. the treatment must be acceptable according to standards of medical practice, and 5. treatment must be reasonable and necessary with consideration for the patient's condition. Please refer to the CMS website for additional information regarding skilled therapy and the changes in Medicare reimbursement.
Chapter 2. Clinical Populations Encountered by the Medical Speech-Language Pathologist
While working within various medical settings, the med SLP will come into contact with diverse patient populations with needs specific to their unique diagnoses. However, med SLPS working in specific settings may see more of a specific type of patient or medical diagnosis than others. For example, med SLPs working in SNFs will generally have a high cognition and dysphagia caseload while a med SLP working for the Veterans Affairs (VA) Hospitals may work with a higher percentage of traumatic brain injuries (TBIs). A med SLP working in an LTACH will frequently work with tracheostomies and ventilators. In this chapter, the main patient categories are identified along with the role of the SLP in working with these specific populations. The clinical populations and examples of the various diagnoses detailed in this section include;
Developmental disorders: cerebral palsy, muscular dystrophy, Down syndrome, autism spectrum disorder
Acquired brain injury: stroke, traumatic brain injury
Neurodegenerative disorders: Parkinson's disease, multiple sclerosis, amyotrophic lateral sclerosis, Huntington's disease
Encephalopathy: toxic-metabolic encephalopathy, chronic traumatic encephalopathy, encephalitis, HIV-related encephalitis and encephalopathy
Psychiatric disorders: attention-deficit hyperactivity disorder, schizophrenia and schizoaffective disorders, delirium
Cardiac and respiratory disorders: chronic obstructive pulmonary disease, acute respiratory failure, heart failure and ventricular assistive devices
Head and neck surgery: lip surgery, tongue surgery, surgery of the oropharynx, surgery of the hypopharynx and larynx, base of skull surgery, anterior cervical discectomy and fusion
Esophageal disorders: gastroesophageal reflux disease, esophageal motility disorders, upper esophageal dysfunction
In each of these clinical populations, the authors provide an overview of the clinical population with specific examples of the various diagnoses which fall within that clinical population, detail the potential impacts on communication or swallowing, and explain the role of the SLP in working with these patients at various levels of care. At the end of the chapter, 5 case studies are provided to demonstrate real-life applications of the material presented in the chapter.
Chapter 3: A Guide to Neuroimaging for the Medical Speech-Language Pathologist
Technology to view and study the human brain has advanced, particularly in the last couple of decades. Neuroimaging provides information including identification of brain disorders, likely clinical presentation based on the areas of the brain implicated, prognosis, and biomarkers for predicting recovery. As part of the interdisciplinary medical team, it is important for the med SLP to have an understanding of neuroimaging because; (1) it allows the med SLP to predict likely impairments in cognition, communication, and.or swallowing based on the areas of the brain implicated which can guide assessment and treatment, (2) it can provide insight into possible changes in cognition and communication function over time. and (3) the med SLP will likely serve a role in helping patients and their family members to understand the neuroimaging results, particularly in relation to cognition, communication, and swallowing.
In this chapter, the various types of neuroimaging are reviewed along with their advantages, disadvantages, and factors which can contribute to their overall quality including; temporal resolution (time scale in which images can be captured), spatial resolution (the minimum size of a brain region that can be distinguished from another brain region or the maximum number of brain regions which can be observed at a given time), signal-to-noise ratio, contrast, and the presence of artifacts (disruptions which can negatively impact the quality of a study). The types of neuroimaging included in this chapter (detailed below) are those currently being used in clinical practice and are not solely for research purposes.
Computed tomography (CT)
Positron emission tomography (PET)
Magnetic resonance imaging (MRI)
Functional magnetic resonance imaging (fMRI)
Magnetic resonance spectroscopy (MRS)
Diffusion weighted magnetic resonance imaging (DWI)
Electroencephalography (EEG)
Magnetoencephalography (MEG)
Neurosonology
Chapter 4: Clinical Considerations of Medication Use in Patients with Swallowing and Communication Disorders
While med SLPs do not prescribe medication for patients, it is important for the med SLP to have an understanding of the possible impacts of medication on swallowing and cognition as well as the timing of medications to maximize patient function. Many of our patients may also experience pill dysphagia or difficulty swallowing pills which can negatively impact medication adherence. At the beginning of this chapter, the authors provide an introduction to pharmacokinetics (the effects the body on medication), pharmacodynamics (the effects medication a can have on the body), and the pharmacological effects of medications though neurotransmitters and receptors. A detailed chart is provided outlining the neurotransmitters, receptors, physiologic function, the clinical consequences of stimulation or blockade of the receptors, and common clinical uses.
Medication and Dysphagia
Many patients in a medical setting may experience dysphagia from a variety of etiologies as detailed in the description of Chapter 2 and others such as polypharmacy and autoimmune diseases. Swallowing is a highly complex process requiring the coordination of voluntary and involuntary actions. Primary mechanisms through which medications can negatively impact swallowing function discussed in this chapter include inhibiting or exciting muscle function during the oropharyngeal stage of the swallow, esophageal injury, and decreased lower esophageal sphincter pressure. Certain medications may also cause xerostomia (dry mouth) which can make chewing and swallowing uncomfortable or painful. A chart is included in this chapter which organizes various medications by the mechanisms through which they can impact swallowing function. In other cases, medications such as Botox and Parkinson's medication (e.g., carbidopa/levodopa) can be utilized to improve swallowing function by managing symptoms such as hypertonicity and spasms (Botox) or rigidity and bradykinesia (associated with Parkinson's) which can result in swallowing dysfunction.
Patients, especially in the older population, may experience pill dysphagia. In this situation, interventions may include changing the route (e.g., providing a liquid form instead of a solid tablet), nonoral routes of administration (e.g., transdermal), crushing or splitting tablets, placement in semisolids, dissolution in liquids, or thickening liquid medications. Communication with physicians and nurses regarding medication delivery is critical as some medications, such as delayed-release tablets cannot be crushed and medications like Miralax cannot be thickened. A chart is included in this chapter detailing medication formulations which cannot be crushed or altered and an algorithm for medication management with adults with swallowing difficulty.
Medication Induced Speech, Language, and Cognitive Disorders
Although further research is indicated, cases including medication-induced aphasia and stuttering have been reported. Medications that cause tremors may also impact written and verbal communication as well as voice. Included in this chapter is a chart detailing various drug classes and specific medications that cause tremors. More information is available regarding the effects of certain medications on cognitive function. Mechanisms of cognitive impairment include sedation, confusion, amnesia, and delirium. A chart is included in this chapter detailing the classes of medications implicated in the specific mechanisms of cognitive impairment. It is important for the med SLP to have a strong relationship with the pharmacist and physician. In some situations, different medications or a lower dose may be effective in reducing the effects or exacerbation of cognitive-communication and swallowing disorders. The med SLP may also contribute to ruling out other causes of cognitive impairments such as CVAs.
Chapter 5: Infection Control Precautions for the Speech-Language Pathologist
This chapter is particularly timely given the COVID-19 pandemic occurring at the time this blog post was published. Med SLPs will come into contact with patients with infectious diseases in medical settings. Med SLPs are also often involved in aerosol-generating procedures or procedures that result in the spread of airborne particles through coughing or sneezing. Such procedures include dysphagia assessment and treatment, instrumental assessment of voice, management of patients with laryngectomies, tracheostomies, and working with patients who require supplemental oxygen via high flow nasal cannula. It is important for the med SLP to comply with recommended precautions in accordance with the Center for Disease Control (CDC) and the policies of specific medical settings to protect both themselves and the patients with whom they come into contact. Please refer to the ASHA Guidance to SLPS Regarding Aerosol Generating Procedures for information specific to the COVID 19 pandemic. In this chapter, standard and transmission-based precautions are detailed. Charts are also included in this chapter detailing types of precautions along with a description and the recommended PPE, standard precautions to minimize the rest of infection in the outpatient setting, and methods of transmission and precautions for commonly occurring infections.
Impressions:
Medical Setting Considerations for the Speech-Language Pathologist is an excellent resource for graduate students, new clinicians, SLPs looking to change medical settings, and seasoned clinicians who wish to learn more about neuroimaging or the impact of specific medications on their patients' overall function. This book provides information including; the different team members with which the med SLP may come into contact, the types of patients med SLPs may encounter in various settings as well as assessments and interventions which may be considered based on the specific impact on communication, swallowing, and cognition, various neuroimaging techniques, medications which may impact overall patient function, and precautions to ensure the safety of the SLP and their patients. Often in SLP forums, there are many frequently posted questions by new and experienced clinicians alike such as the role of the SLP in treating patients with delirium or the long term effects of altered mental status on cognitive function. Medical Setting Considerations for the Speech-Language Pathologist should answer many of those frequently asked questions. Case studies are also provided at the end of the chapters to tie the information presented in real-life contexts. Prior to reading this book, I had not considered the role of the med SLP in working with hospitalized or institutionalized patients with developmental disorders who are typically managed by pediatric or school-based SLPs. As a result of reading this book, I feel more empowered to help these other patient populations. The detailed charts are also invaluable reference materials for SLPs at all stages of their careers. This is the first book in Plural Publishing's Medical SLP series. Stay tuned for our review of the second book in the series, Primary Progressive Aphasia and Other Frontotemporal Dementias: Diagnosis and Treatment of Associated Communication Disorders.
*** Disclosure: The author received a complimentary copy of this book from Plural Publishing for review.