Determining Skilled Need

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There are four primary criteria that you need to look at. The first is, is there an evidence base for what I am doing? The second is, are the services complex and sophisticated in nature? The third deals with medical diagnoses, and the fourth deals with the individualization of frequency and duration of care. Let’s go through each of these individually.

Evidence-based practice - What do we know about the definition of evidence-based practice? We know it is tri-fold in nature, to begin with. Evidence-based practice includes what we see in the literature for speech-language pathology. Evidence-based practice also includes what we know from our clinical experience as a speech-language pathologist, and finally, evidence-based practice includes that component that deals with the patient's wishes, and the patient's desires, and the patient's needs. If you are looking for more education or training on what evidence-based practice truly means, I would advise you to look at the literature from Dr. David Sackett. He was one of the first individuals that really talked about that tri-fold nature of evidence-based care.

We have to adhere to evidence-based practice. For this purpose, I have found it useful to look at ASHA's evidence-based maps. If you have not had the chance to look at the new practice portals - the evidence-based maps that ASHA has added to their website - I highly recommend that you look there. I am looking in that system on a weekly basis. There is a ton of information. It is well organized, taking the patient all the way from prevention, to assessment, to treatment, to follow-up. The way that they have it structured really leads to ease of access. That is a good way to follow evidence-based practice patterns.

Complexity and sophistication of services - The level of treatment that you provide must be complex, and it must be sophisticated in nature, meaning that no one else except for a skilled speech-language pathologist can provide that level of care. On the other hand, just because you are providing a service does not make it complex and sophisticated in nature. When you are providing care, you need to think about, “What am I doing to adjust? What am I doing to alter? What am I doing to change the way, for example, that a one-step direction is given to a patient? What is unique about the level of care that I am providing?” Let me provide a real-life example for everybody. Let's say that you have a patient who is status post TBI, or an individual that has dementia that has impacted the frontal lobe.  He is very impulsive, and has poor judgment, and refuses care from nursing assistants or family members. Perhaps as an SLP, you can go in and train those caregivers that when they are speaking to Mr. Jones, they need to ask questions that are close-ended versus open-ended. Open-ended questions are going to frustrate him. The caregivers know that for the past 30 years, Mr. Jones has had black coffee for breakfast, so they should not ask him what he wants to drink for breakfast. Instead, they should say, “Mr. Jones, would you like your black coffee for breakfast? Yes or no?” That takes the burden off of the caregiver, and allows the patient the opportunity to be successful and engage in making that choice. That is a simple example, but as an SLP, you may be the only one that is able to analyze the situation and make that level of a recommendation. So take credit for that. Realize your skillset; know what you are able to do that no one else can.

Medical diagnoses - The third aspect deals with medical diagnosis, and it may be different than what you think.  Medicare is very clear that medical diagnosis alone does not determine the need for skilled treatment. That means that we should never let another team member tell us, “Mr. Jones has progressive dementia. He is in Stage 7. There is nothing you can do for him,” or “Mr. Adams had that stroke six years ago, and those are residuals. There is nothing you can do for him.” Medicare says the opposite. They say that we should never look at medical diagnosis alone as the sole determining factor for whether or not we treat somebody. Instead, you look at whether there is an evidence base, and whether what you are doing is complex and sophisticated.

Individualized frequency and duration - The final piece is related to whether you are providing care at an appropriate frequency and duration. When you are treating, each individual patient should have an individualized frequency and duration of care. There are no static roles tied to frequency and duration and the payer. I will say that with a little aside, because we are seeing huge growth of managed care options in the industry, and under managed care, you may be given a certain number of visits. But you, as the SLP, can determine the frequency and duration based on the individual patient's needs. Maybe you have a patient with new onset TBI, and you are using a top-down approach, which we will discuss later as one of the evidence-based approaches, and you know that the evidence tells you that treating more intensely at the beginning of care and tapering towards the end of care is more appropriate. In that case, your frequency and duration should reflect that. Perhaps you are treating someone with dementia that is in Global Deterioration Scale (GDS) Stage 7, and you are establishing a functional maintenance program for the certified nursing assistants.  Your frequency and duration might be three times a week for four weeks so that you can go in at various intervals and assess multiple areas of caregiver understanding -- assessing their verbal understanding of techniques, and also their return demonstration of techniques. Just know that as the skilled therapy provider, you are the one that sets the individual frequency and duration.

Please refer to the SpeechPathology.com course, Treatment of Patients with Low-Level Cognitive Function, for more in-depth information on evidence-based practice methods for speech-language pathologists on the treatment of patients who present with low-level cognitive functioning due to new onset and progressive neurological conditions.