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What are medical SLP skills needed for a particular work setting?
Competence in the skills and knowledge of communication disorders causes and effects regarding the physical, anatomical, physiological, and psychological processes. Cause-effect, medical model
Describe the SLP continuum of care.
What are examples?
- SLP can practice in variety of settings (academic facilitates, community hospitals, outpatient clinics, subacute, rehab settings, home care, SNF, hospice)
- Rapid changes in communication and swallowing when practicing in acute care which is consultative. In chronic care work to strengthen functional communication for patients whose impairments are stable
What are competencies?
Skill and knowledge bases required for ensuring safety of patients and for proper interpretation of results
What are implications of specialty development in neurogenic communication disorders/dysphagia? Will you pursue one/both of these areas? Why?
Dependent on cost, interest, job market; both are more prevalent within our scope of practice, making it necessary to have competency in both areas.
Important trends in ASHA 2002
- Less than 2% SLPA's
- 45% spent time training/supervising students
- 31% dysphagia
- 50% cog/comm disorders
- 66% AAC referrals
- 69% difficulty hiring qualified SLPs for setting
2 types of brain damage as result of TBI
- Open (result when scalp, skull, and meninges are penetrated, like a gun shot wound)
- Closed (result when mechanical force results in skull fractures and tissue damage to underlying brain surface
- Acceleration-deceleration; contrecoup; DAI
Factors to determine severity of TBI
- Distribution of injury (focal, multifocal, DAI)
- depth of lesions
- type of underlying pathology
- Duration of coma
- PTA (post traumatic amnesia)
Main cognitive disturbances seen after TBI
attention, memory, organization, reasoning, EF, communication, social skills, orientation/arousal, awareness
Distinction b/w aphasia and confused language
Aphasia: Acquired impairment of language processes underlying receptive and expressive modalities caused by damage to areas of brain for language function; Grammatical disturbances, word retrieval difficulties, AC, reading, writing, speaking; Relatively intact cognitive abilities (orientation, attn, memory)
Confused language: Receptive/expressive language may be phonologically, semantically, syntactically intact but lacks in meaning because responses are confabulatory, circumlocutory, or tangential in relation to topic; lacks logical sequence
Confused language may be mistaken for fluent aphasia but is more considered cognitively based vs. linguistically based. It is ay difficulty with an aspect of communication secondary to cognitive dysfunction.
Purpose of WHO's ICF?
Domains/definitions of each
Standard framework for description of health and health-related states as they relate to contextual factors, both environmental and personal.
- Body function and structures: Interruption of normal physiologic processes, body functions, or structures through injury or disease
- Activities and participation: Ability to execute particular task, ability to be involved in life situation
- Environmental tasks: External influences on functioning; includes individual factors such as those in immediate environment of individual and octal factors such as informal social structures or systems
- Personal factors: Personal influences on performance (e.g. gender, race, age, education, style)
5 stages of TBI rehab continuum
- 1. Acute care (primary goals are medically oriented; evaluation and diagnosis of communication/swallowing disorder)
- 2. Sub acute: Medically stable but too weak to fully participate in and benefit from aggressive inpatient rehab program; ongoing assessment an treatment of disorders. Skilled nursing care provided may be ECF or SNF
- 3. Inpatient rehab: Intensive multidisciplinary rehab; must actively be involved in minimum of 3 hours of therapy per day and have ongoing goals in at least 2 services; maximize independence
- 4. Outpatient: Discharged home but continue rehab on outpatient basis at clinic or department or through home care agency, usually 2-3 times a week; focus on community reintegration
- 5. Community reintegration: begin early in rehab; job coaches, supervision at home, AAC, transfer of skills
Restorative vs. compensatory approaches and underlying rationales for each
Restorative: Neuronal growth, resulting in improvements in function is associated with repetitive exercise of neuronal circuits; involves repetitive exercises and drilling; muscle building approach
- Compensatory:Certain functions cannot be recovered and development of strategies to circumvent impaired functions is primary goal
- **Compensatory approach should not be implemented until restorative has failed. Both should overlap and occur simultaneously
Describe notion of goal planning as it pertains to TBI rehab (principles)
- 1. TBI patient should always participate in goal setting
- 2. Goals selected should be reasonable, client-cenetered
- 3. Goal should contain description of behavior when goal is attained
- 4. Method for achieving goal should be clearly delineated
- 5. All goals should be specific and measurable with definite timelines
Factors to consider when selecting standardized batteries that are appropriate for TBI
- Stage of recovery; pre injury traits
- Rate of presentation, type of response required, duration of task/length of testing sessions, context in which stimulus is presented, patients' attention, sequencing, orientation, communication abilities
- ASHA FACS, Behavior Rating Inventory of EF
- (Also, Western Neuro Sensory Stimulation Profile, JFK Johnson Rehab Institute's Coma Recovery Scale)
Describe ongoing, collaborative, contextualized, hypothesis-tsting assessment approach. How does this approach differ from more traditional evaluation procedures?
Dynamic assessment based on context, collaboration, and hypothesis-testing according to the client. Rationale is delivery, complex profiles, context-sensitivity, collaboration, change, flexibility.
Differs because it is based client's vocational, academic, and social behavior to obtain most salient features of their true deficits that standardized assessments don't always catch. Collaboration with staff and family also contributes to assessment and intervention
Describe the 5 primary purposes of documentation.
- 1. Patient care: Primary means of recording/communicating patient's past medical history, current concerns, clinical evals, impressions, recommendations for tx, justification
- 2. Billing and reimbursement: Medicare, fiscal intermediaries, other 3rd party payers; Medical necessity, change of condition, PLOF, reaosnable/necessary, specific, effective, skilled, functional goals, measurable, proper coding, denials/appeals
- 3. Research: Data collected through checklists, standardized measures, rating scales to translate into outcomes
- 4. Legal evidence: Proof for patient cases involving TBI, medical, or professional malpractice, corporate negligence or disability determination
- 5. Compliance and Performance Improvement: JCAHO and CARF standards for documentation of patient care
Why is the concept of medical necessity important in clinical documentation?
- Many health insurance plans base decisions of coverage or payment of services one extermination of medical necessity
- Services delivered may be deemed unnecessary and not paid for if not proven necessary ind documentation
- Be familiar with insurance plan before requesting authorization or payment b/c medical necessity may be defined differently among insurance companies
- Medicare has guidelines for justification
Identify and define 6 medicare documentation guidelines
- 1. Change of condition: medical event that causes a need for skilled intervention
- 2. PLOF:patients previous level of functioning prior to the change in condition; seek tx for PLOF
- 3. Reasonable and necessary: Amount, frequency, duration must be appropriate for diagnosis under accepted standards of practice and should reflect patient's response to treatment
- 4. Specific: Tx must be targeted to pre-established and documented treatment goals and must be clear/measurable
- 5. Skilled: Tx needs and strategies to attain goals must be so complex and sophisticated that it requires knowledge, skill, and judgment of SLP
- 6. Measurable: Should be written to show patient is making progress or has potential for functional gains
Define STG and LTG and provide example of each. What criteria/components are needed to create functional and measurable goal? Provide example of good goal and bad goal.
- LTG: Representation of communication or swallowing behavior that is expected at the end of treatment. End result of treatment
- STG: Representation of a step required to meet LTG
- To create functional/measurable goal: target skill related to ADLs and increase communication/swallowing independence. To be measurable, must be objective way to determine progress. Time frame for accomplishing STOs and LTGS is recommended for Medicare/private insurance
- Functional and measurable: LTG: In order to facilitate successful communication, the individual will utilize a communication book w/o cues in 90% of opportunities over 5 consecutive sessions within 4 weeks.
- STO: Over 2 weeks, individual will use communication book with minimal cues with 80% of opportunities over 3 consecutive sessions.
- NOT functional/measurable: Individual will improve naming of types of vehicles
- Improve does not lend itself to objective way of measuring; doesn't help communicate physical emotional needs, more successfully with family and friends, more effectively in community
What is the difference between CPT and ICD-9 codes? why is it important that the SLPs documentation supports the codes used for each patient?
- CPT (Current procedure terminology): used to describe the procedures, treatment, or
- service that health care providers use with patients; divided between time and
- service and evaluation and therapeutic codes
- ICD-9 (International Classification of
- Diseases-9): used to code etiologies, symptoms, diseases, and injuries that the
- health care provider is evaluating or treating
- It is important that documentation supports the codes used for the
- patient for billing purposes. Gov’t & private insurance co. compare ICD-9
- & CPT codes to check for a reasonable relationship between procedure &
- the disease. Inaccurate CPT codes can lead to fraud and abuse charges
- (e.g. overpayment). Also, if 3rd party payer does not recognize CPT code, they
- will deny payment for services.
The accrediting agencies,
JCAHO and CARF, have multiple standards for documentation of patient care.
Identify the information that must be documented when a patient is referred,
transferred, or discharged from treatment in order to meet JCAHO standards.
- Reason for transfer, referral, discontinuation
- of services/discharge
- Patient’s physical and psychosocial status
Summary of care provided, progress toward goals
- Community resources or referrals provided to
The Health Insurance
Portability and Accountability ACT (HIPAA) has impacted patient confidentiality
in documentation. Under HIPAA’s second rule, a patient’s identifying
information is considered protected health information. To comply with HIPAA
standards, what must the treating health care professional obtain from the
patient before disclosing any protected health information (for purposes other
than treatment, payment or operations)? Additionally, HIPAA requires that
providers offer patients a notice of their privacy practice. What must this
- Treating health care professional must obtain the
- authorization (consent) from the patient and offer patients a notice of their
- privacy practices and request their acknowledgment of this notice that includes
- a summary statement of providers’ health information practices as well as
- notification that patients have the right to request certain restrictions on
- how their information will be disclosed
Research that supports the efficacy of our
services is critical for survival of the profession through continued
reimbursement of services. What documentation formats are recommended for
efficient and effective collection of research data?
- Standardized measures
- Rating scales (e.g. FCM)
Results of length, format, and terminology of
survey of physician documentation preferences. How will they impact
documentation in the work setting?
- 88% of physicians said they would like short and
- concise, one-page reports
- The majority of physicians said they mostly read
- the summary, impressions, and recommendations, sometimes read details about
- tests given, and would prefer to see the test results in a check list form as
- an attachment
- 76% of physicians said they prefer reports to be
- in common or simple language
- Based on the results of this survey, my
- documentation in the work setting will change. This will not only provide
- better information for the physicians, but will allow me to think more
- cohesively and concisely and analyze the most salient features. I will most
- likely provide less but concise information about tests given rather than minor
How can a computerized documentation system
increase quality of services to patient and family and increase productivity
and revenue? How can negative clinical and ethical implications be avoided?
- There are many benefits to computerized documentation. It increases the quality
- of services by reducing spelling and grammatical errors, increases the
- accuracy of information, and reduces billing errors. It also ensures that
- the reports (that are typed) are legible and secure. Computerized
- documentation increases productivity by decreasing the redundancy of data
- entry. Drop-down lists reduce time spent choosing the appropriate wording
- and reports can be sent in a timely manner to physicians, patients, and third party payers. Eliminating copying and mailing expenses as well as transcription costs increases revenue through the use of computerized documentation.
Some negative clinical and ethical implications may arise with computerized
- documentation. Because templates are available, clinicians should be sure
- to individualize each document to their specific client. Failing to do so could affect the client’s insurance because it would not justify the
- specific client’s need(s) for treatment.