Evolving Roles for SLPs: Surviving and Thriving in a Transforming Health Care Environment

Evolving Roles for SLPs: Surviving and Thriving in a Transforming Health Care

Environment

Becky Cornett, Charlette Green, Ann Kummer, Nancy Swigert, Molly Thompson

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Disclosures:

• Non-financial: Each presenter served on the ad hoc committee for Reframing the Professions. Much of this content is drawn from the final report.

• Becky Cornett – No financial disclosures

• Charlette Green – No financial disclosures

• Ann Kummer – No financial disclosures

• Nancy Swigert – No financial disclosures

• Molly Thompson – No financial disclosures

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Topics:

• Healthcare payment trends (Becky) Nancy subbing for Becky • How this impacts SLPs in education settings (Charlette)• Using outcomes data to inform practice decisions (Nancy)• Focusing on function in goal writing and service delivery (Charlette)• Looking beyond “typical” roles of the SLP (Nancy)• Working at top of license/shifting responsibility (Ann)• Streamlining documentation (Molly)

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ASHA ad hoc Committee on Reframing the Professions• Final report submitted December

2013

• Available at: http://www.asha.org/uploadedFiles/Reframing-the-Professions-Report.pdf#search=%22reframing%22

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Payment Trends in Health Care: Update on the Journey to Value

Becky Cornett

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Who is driving the change?

• Purchasers• Employers

• Government payers

• Individuals

• Asking health care providers to focus on improving health status of the patient

• NOT focusing on discrete visits, procedures, surgeries that are not coordinated , are of inconsistent quality and do not consider cost incurred by all stakeholders

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Providers are asked to be accountable by assuming risk

• Performance: by meeting quality indicators

• Utilization: moving high cost acute care to other venues

• Financial: accepting payment to cover all services within a certain time period

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The Journey from Volume to Value: Outcomes that Matter to Patients are the Bottom Line

“A Tectonic Shift is happening in health care, where outcomes are the bottom line and where the system conforms to the patient, rather than the patient conforming to the system” – Optum Health

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Goals of Health Care Reform

• Improve quality & experience of care for individual patients; improve health status of populations; contain costs.

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IOM’s Definition of Quality: It’s all about achieving outcomes (results)

• Quality: the degree to which health services for individuals and populations increases the likelihood of desired health outcomes and are consistent with professional knowledge

• Health outcomes and payment in the future will be commensurate with results achieved relative to the costs incurred by health care purchasers.

Source: Institute of Medicine

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The Value Question: What results are we getting for our money?

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Critical importance of measuring and achieving value for all stakeholders

• Measuring the value of health care requires us to integrate clinical and financial performance; focusing on the total costs and resource use associated with the outcomes providers and persons served achieve together.

• Achieving high value for patients must become the over-arching goal of health care delivery. If value improves patients, payers, providers and suppliers can all benefit while the economic sustainability of the health care system increases.

Source: Michael Porter, Ph.D., Institute for Strategy & Competitiveness, Harvard Business School http://www.isc.hbs.edu/Pages/default.aspx

• Pointed concerns about the economic sustainability of the health care system – especially relative to questions about the mediocre health status of much of the population –has brought us to this juncture

•

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Payment Changes Prompting the Evolution of Clinical Practice & Journey to Value

• Since 1999 reports published on high rates of errors in hospitals & poor health status in U.S. compared to other nations – despite spending more on health care than any other nation.

• Effectiveness questioned – Americans receive only 55% of indicated care – yet overuse and misuse of care rampant.

• Care inefficiencies – 30% of spending attributed to waste. • Care disparities/inequities evident - based on race, ethnicity, socio-

demographics.

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Fee-for-Service(FFS) system under fire: providers focus on volumes of services, not

value • FFS system encourages more services and more expensive

procedures. • Care is largely transactional, not coordinated. • Wide variation in treatment patterns – not based on evidence but

on individual practitioner preferences.• No assurance of quality – payment not tied to safety, efficiency, or

results. 14

The Journey from FFS Payment to Provider Risk Models

• Both government and commercial payers are moving rapidly to encourage providers to accept performance risk (quality indicators; outcomes measures) and financial risk (responsible for costs and results of care within defined parameters- which may range from a payment bundle for a patient condition such as “stroke” to per-member-per-month payments for ALL care needed for an “enrolled life”).

• The trajectory of change depends on many factors, including regional and local market forces.

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The Hierarchy of Financial Risk to Providers

Source: AthenaHealth Knowledge Hub ©201416

Payment Model Hierarchy based on provider performance and financial risk

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The Transition from Volume to Value

• Value-based payment is expected to overtake traditional fee-for-service by 2020, with 2/3 of payments involving provider risk contracting.

• The majority of payers are already using some form of value-measurement (value-based purchasing or “pay for performance” which offers incentives for meeting certain metrics).

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Medicare’s Value-Based Purchasing Program

• The Hospital VBP Program rewards (or penalizes) hospitals based on quality metrics. CMS withholds part of the annual payment update - hospitals can earn back the withheld amount by meeting goals re: processes of care, morality, readmission rates, patient experience of care, hospital-acquired infections.

• There is also a hospital outpatient VBP program as well as one for IRFs, SNFs, and Home Care].

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Current VBP-Related Programs For SLPs

Claims-Based Outcomes Reporting

http://www.asha.org/Practice/reimbursement/medicare/Claims-Based-Outcomes-Reporting-for-Medicare-Part-B/

PQRS: (for SLPs in private or group practices) http://www.asha.org/News/2014/Medicare-Releases-2013-PQRS-Participation/http://leader.pubs.asha.org/article.aspx?articleid=1854288

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Next in the Hierarchy of Risk: Bundled Payments for Episodes of Care

• Bundled or episodes of care models provide a single negotiated payment for all the services needed for a specified procedure or condition (e.g. joint replacement, stroke, COPD, AMI) over a specified time period (30, 60, or 90 days typically).

• Over 500 hospitals and providers have enrolled in CMS’ Bundled Payment for Care Improvement program to date; more than 6,000 hospitals, physician group practices and post-acute care providers have applied to participate CMS’ Bundled Payment for Care Improvement (BPCI) program in 2015.

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Bundled payments, continued

• Most bundled payment contracts to date – governmental or commercial – are retrospective: participants bill FFS claims as usual, but a reconciliation process determines the final payments for the episode, comparing the aggregate amount to the pre-established discounted bundled price to be paid.

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Depiction of Traditional FFS vs. Bundled Payments

Source: Stryker Performance Solutions. Bundled Payments. © 2014

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Communication and collaboration are key. No one wants to be the provider who adds cost

What about “Accountable Care” and ACOs?

• Accountable care refers broadly to organizing and delivering health care services focused on achieving superior health outcomes while demonstrating a high degree of stewardship of financial, human, and material resources.

• “Accountable care” is the responsibility of all, not limited to an Accountable Care Organization (ACO).....

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What is an ACO?

• An ACO is a coordinated system of providers who are responsible for all of the health care and related expenditures for a defined (attributed or enrolled) population.

• An ACO may operate under a variety of payment models simultaneously according to contract terms.

• There are 600 + ACOs nationwide.

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ACOs, continued.

• To be successful, ACO providers must operate as a high-performance network that is aligned, patient-centered, collaborative, and accountable for results.

• Providers integrate the clinical and financial aspects of care, reporting externally on the outcomes and costs of care –continuously reviewing data to improve results- for patients and for the organization. Robust data analytics is critical to success.

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Example of an ACO Model – the ACO does not need to own all components

27Source: clinical-innovation.com

Capitated Payment Models

• Full risk capitation means that providers are responsible for all services (hospitalization, ancillary services, procedures, tests) and costs associated with the health of a population under contract often paid via PMPM – “per member, per month” payments.

• Partial capitation involves a single monthly fee for a defined set of services associated with sub-sets of clinicians and/or patient conditions.

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An Era of Mixed Payment and Service Delivery Models

• It is likely that provider organizations will be involved in some or all of the value-based payment models over the next few years.

• Meanwhile, new provider-payer arrangements are emerging: payers who own clinics and hospitals; hospitals that own health plans; and providers who contract directly with self-insured employers.

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Also: The Growth of Retail Care

• Consumers are footing more of the bill for their own care (the trend is toward high-deductible health plans with co-pays and co-insurance).

• Consumers are price-sensitive, and focused on results that matter to their everyday lives.

• A number of providers, including SLPs, are offering out-of-pocket options including on-line care by subscription, apps, and other programs in lieu of traditional insurance-based office care.

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Key Competencies for Providers: The Next Era of Healthcare

• Integration and alignment among providers across the care continuum -make best practices standard.

• Ability to manage risk – determine and stratify patient risk of high-cost care; target interventions to the facilitators and barriers to participation in daily life activities; consider the multiple determinants of health status.

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Key competencies, continued

• Demonstrate facility with clinical, programmatic, and financial data analytics.

• Determine costs of care and resource use for identified populations in order to contract successfully.

• Demonstrate a “propensity toward value:” willingness to redesign clinical and business models to achieve results; incorporate outcome measurement into everyday practice.

Source: Health Care Financial Mgmt. Assoc. (HFMA)

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How changes in health care environment impact SLPs in education

settings Charlette Green

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Reauthorization of Elementary and Secondary Education Act

• SLPs in the public education setting may find this similar to NCLB of 2001• NCLB Is Based on Four Principles of Educational Reform

1. Stronger accountability for results;2. Increased flexibility and local control;3. Expanded options for parents and 4. An emphasis on teaching qualifications and methods. Of these four, accountability

for results is the principle that has the potential to greatly improve the educational results for children with LD.

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IDEA 2004: Improvement Act

• Special education and related services should be designed to meet unique learning needs of eligible children with disabilities.

• Students with disabilities should be prepared for further education, employment and independent living

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Impact on SLPs in Public Education

• Focus shifted from medical model to an educational model

• Focus on services in the general education classroom

• Focus on generalization outside of the speech room

• Focus on curriculum-based therapy

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Impact on SLPs in Public Education

• SLPs working on educational interdisciplinary teams focusing on educating the whole child

• Focus on evidenced-based practice and accountability

• Shift from sole person responsible to becoming a facilitator of improved communication

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Using outcomes data to inform practice decisions

Nancy Swigert

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Measuring functional change: Outcomes data

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• Describe change in a way that is meaningful to others

• A change in applied aspect of a skill• Individual able to eat an entire meal in reasonable period of time due to….increased

tongue strength

• Individual able to converse with friends over lunch due to …improved receptive and expressive language skills.

Patient-centered outcomes research

• Patient-Centered Outcomes Research Institute (PCORI)

• Independent, nonprofit entity with public and private funding

• AHRQ and NIH Directors serve on PCORI’s board and methodology committee

• Sets priorities and coordinates with existing agencies that support patient-centered outcomes research

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The power of data

Analyze and improve the way SLPs provide services

Provide answers for clients and their families about expected outcome

Provide information to administrators/third party payers about the value of SLP services

Benchmark performance against system and national data

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Outcomes data can be used to:

• Establish baseline status

• Determine effectiveness of interventions

• Inform patients of progress in a quantifiable manner

• Inform payers of progress to enhance reimbursement

• Provide data over time to improve care

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Questions data can answer On average, how many sessions are

needed to treat an adult with aphasia or dysphagia?

On average, how much gain will a patient demonstrate during a given time period within a specific treatment setting?

How many sessions will it usually take to get a patient off tube feeding?

Do patients progress faster with more intensive treatment?

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ASHA NOMS

• ASHA National Outcomes Measurement System (NOMS) Functional Communication Measures (FCMs)

• Multidimensional tool – measures supervision level required and diet level

• 1998 -2012

• 102,541 patients in data base scored on the FCM for swallowing across all settings

• 59,502 scored on swallowing only

• 43,039 scored on swallowing + other FCMs

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Reporting Functional Status

• Outcome measurements scales – FCMs• Disorder specific 7-point scales

• Ranging from least functional level 1 to most functional level 7

• Describes change in functional communication and swallowing over time

• Selected based on individual treatment plan

• Not dependent upon any formal assessments

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NOMS- Adult Functional Communication Measures

AAC Alaryngeal CommunicationAttention Fluency Memory Motor SpeechPragmatics Problem SolvingReading Spoken Language ComprehensionSwallowing Spoken Language ExpressionVoice Writing

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Data collected at two points of care

• Beginning of treatment• Demographics

• Diagnostics

• Functional status

• End of treatment• Service delivery

• Functional status

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Patient characteristics

Medical diagnosis

Age

Raceethnicity

Gender

SLP diagnosis

Patient characteristics

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Service delivery characteristics

• Current treatment setting

• Setting prior to admission

• Previous SLP treatment

• Frequency/intensity of services

• Post treatment setting

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Examples of tools for assessing functional swallowing skills

• Functional Outcome Assessment of Swallowing (WSHA, 1996)

• Functional Outcome Swallowing Scale (Salassa, 1997)

• ASHA National Outcome Measurement System – Functional Communication Measures* (1998)

• Functional Oral Intake Scale (Crary et al 2005)

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Swallowing FCM synopsis

• Level 1: NPO with tube feeding

• Levels 2-4: Tube fed, but may take some PO

• Level 5: All nutrition/hydration by mouth with minimal restrictions

• Levels 6 & 7: Eats independently, some cueing or compensatory strategies

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Moving from NPO to some PO Patients scored on Swallow FCM only

Setting N=Level 1 at admit % Level 5 or higher at discharge from that setting

Acute care hospital 4,951 27.3%

Inpatient Rehab 4,573 33.2%

Skilled nursing facility 1,604 16.7%

Outpatient settings 460 31.7%

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Moving from full or partial tube feeding to full oral feeding

Setting N=Level s 1-4 at admit % Level 5 or higher at discharge from that setting

Acute care hospital 13,834 35.6%

Inpatient rehab 9,470 41.8%

Skilled nursing facility 20,291 38.9%

Outpatient settings 1,975 58.5%

Percentages similar for patients scored on Swallowing FCM + other FCMs N is higher.Presumably those are patients with more impairments (e.g. accompanying language disorders )

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FCM Start Score for Dysphagia Patients at Admission to Acute Inpatient Care

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FCM Score for Dysphagia Patients at Conclusion of SLP Treatment in Acute Inpatient Care

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FCM Start Score for Dysphagia Patients at Admission to Inpatient Rehab

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FCM Score for Dysphagia Patients at Conclusion of SLP Treatment in Inpatient Rehab

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Proportion of patients on feeding tubes at admission who received all nutritional intake by mouth at discharge, by treatment setting

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Patient-reported outcomes

• Patient reported outcomes (PRO) have been defined as "any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else." (FDA 2010)

• PRO tools measure what patients are able to do and how they feel by asking questions.

• These tools enable assessment of patient–reported health status for physical, mental, and social well–being.

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Patient-Reported Outcomes Measurement System (PROMIS)

• PROMIS (funded by NIH): A system of tools that measure patient-reported health status, including symptoms, function, and well-being

• Use of PROMIS data:• Evaluation of effectiveness of interventions for various conditions

• Research in chronic health conditions

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NIH's Patient Reported Outcomes Measurement Information System (PROMIS).

• “While PROMIS and other initiatives have validated patient-level outcome measures and instruments, there are two major challenges to using them for purposes of accountability and performance improvement:

• They are not in widespread use in clinical practice.

• Little is known about aggregating these patient-level outcomes for measuring performance of the healthcare entity delivering care.” (Pace, n.d.)

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Several examples of PROs in dysphagia

• SWAL-QOL

• SWAL-CARE

• MDADI

• EAT 10

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SLPs: Seize the Opportunity to “Showcase” Critical Importance of Functional Status

• Use the ICF Framework with care teams to structure care to achieve outcomes that matter to patients’ everyday lives:

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Outcomes that Matter and the ICF Framework

• The ICF framework enables an holistic approach, moving away from incremental improvements in impairments – test scores and % accuracy on discrete tasks; to a focus on all the factors that matter to patients’ ability to participate in the many contexts of life.

• ASHA is forming an Ad Hoc Committee on the ICF charged with applying the ICF framework to goal-setting and outcomes measurement.

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Focusing on function in goal writing and service delivery

Charlette Green

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Functional Goals

This • Focusing on what is important to the

student/patient/client first• Information from assessments inform

mastery criteria but are not the sole source of goals.

• Focus is on the real world and is multidimensional!

Not This• Focusing on arbitrary goals

determined by the SLP alone

• Goals are derived from therapist-given tests alone.

• Focus is one dimensional!

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Service Delivery

This• Address goals using materials and

in the environment where the student/patient/client will be responsible for using them.

• Focus is on generalization!

Not This• Address goals with un-meaningful

materials in separate settings without concern for carry-over or generalization.

• Focus on skill-drill in the separate setting.

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Anticipated End Result: The Student/Patient/Client is:

• More involved in the evaluation process

• More involved in determining the goals and mastery criteria

• Therapy is more meaningful because it is patient focused/centered

• Therapy materials use real world, meaningful materials

• Therapy setting is as close to the natural setting as possible and plans for generalization from the first session

• Patient has more accountability for the outcome vs the SLP fixing the patient!

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Looking beyond “typical” roles of the SLPNancy Swigert

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Moving beyond “typical roles”

• Understand what your facility is trying to do to survive in the new health care arena

• Requires you to understand things like: • Reimbursement methodologies

• Value-based purchasing

• Pay for performance

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Remember the triple aim

• Improving the patient experience of care (including quality and satisfaction)

• Improving the health of populations

• Reducing the per capita cost of health care

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How can the SLP help the facility achieve these goals?

• As facilities move away from department-specific productivity goals based on direct service to patients, SLPs will have the opportunity to demonstrate their value to the facility/system in other ways

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Example: Reducing readmissions

• Hospitals are penalized financially if patients are readmitted within 30 days of discharge

• One of the target populations is patients with pneumonia

• The SLP can have a role analyzing re-admissions and working with the re-admissions team to reduce re-admissions

• Dysphagia screening for any patient with pneumonia?

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Example: Improving patient experience by using more effective teaching methods

• SLPs are experts at communication

• They could be the resource at their facility for teaching other staff how to effectively convey information to patients

• Teach-Back

• Ask Me 3

• SLPs can detect subtle comprehension deficits in patients to determine they are not understanding discharge instructions

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Example: Poor health literacy costs the health care system $$

• The SLP could lead the effort at the facility to address health literacy• Training other staff in what health literacy is

• Helping develop teaching materials and methods to utilize with patients who have varying degrees of health literacy

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Example: SLPs as case managers

• In order to keep patients in their homes and out of more expensive care settings, case managers/coaches are being utilized

• Call the patient after discharge

• Help arrange follow-up MD visits

• Pick up meds and organize them

• Could SLPs be the case managers for patients with communication disorders?

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Example: SLPs as coaches for parents of toddlers

• Instead of seeing only children with defined delays in development, SLPs could instead coach parents of any young child in speech-language development

• Helping parents develop skills to help prevent deficits

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Disruptive technologies

• Be prepared for a time when technology takes the place of something SLPs do--- what if ?

• Apps on I-pad could improve receptive language as well as 1:1 therapy

• Digital screening device for dysphagia eliminates need for clinical swallow exams

• Medication advances eliminate Parkinson’s, Dementia

• Computer-based program can diagnose school-age language disorders

• An implantable device eliminates pharyngeal dysphagia

• Tele-health becomes the standard method of providing services

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Working at top of license/shifting responsibility

Ann Kummer

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Top of License(AKA Leveraging)

• HC providers should ONLY spend time doing things that require their professional skills and training

• HC providers should NOT spend time doing things that can be done by those who are less skilled and lower paid

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Top of License

• For MDs, expanded services can be provided by:• Nurse practitioners

• Physician assistants

• Pharmacists

• Social workers

• Administrative staff

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Top of License

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Top of License

• More cost-effect to have lower paid, less skilled people (i.e., support staff) to support services

• HC provider can see more patients (increase access), and generate more revenue

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Top of LicenseWhen professional people work at the top of their license…

• Win for the professionals

• Win for the patients

• Win for the business

Top of License for SLPs

• SLPs should provide only those services that require a level of complexity and sophistication that only an SLP can perform.

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Top of License for SLPs: Admin Support

• Administrative support

• Paid support staff

• Students

• Volunteers

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Dedicated support staff should do all of the following:

• Scheduling

• Insurance auths

• Phone calls

• Mailing of letters, reports, etc.

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Pre-visit planning by support staff:

• Pre-evaluation questionnaire (paper, online, or on phone)

• Pre-visit parent interview

• Use of self-management questions when making appointments to ensure commitment and attendance

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• What if you can’t afford to hire support staff ?

• Actually, you can’t afford NOT to hire support staff.

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Cost per hour when SLP schedules: ($33.65)

Revenue per hour when a support person schedules and the SLP treats a patient:Revenue from charges: $200.00Cost for SLP: ($33.65) Cost for support staff: ($15.00)

Profit $151.35/ per hour90

Activity: Cost of Wasted Time

• One cherry tomato…

• One hour per week…

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Question at the ASHA Business Institute: 2013What would an SLP prefer to do?

1 2 3 4

0%

98%

2%0%

1. Schedule a patient

2. Obtain insurance authorization

3. Produce a diagnostic report

4. Treat a patient


SLPs should not do administrative tasks

• SLPs are happier doing clinical work

• SLPs are not that good at admin tasks

• SLPs time = access and money

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Top of License for SLPs: Clinical Support

• Clinical support

• SLP assistants

• Students

• Volunteers

• Parents/family members

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To increase your support and decrease your costs:

• Develop a Student Volunteer Program

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Use students to:• Set up and clean up• Organize materials and

cabinets• Make copies• Run errands• Call families

• Make communication boards, handouts, etc.

• Take a history over the phone• Do literature reviews• Do crafts for use in therapy

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Student Volunteer Program at Cincinnati Children’s

• Undergrads or grads in speech-language pathology

• Student commits to a min of 4 hours/wk for 12 wks

• Student signs a “contract” with expectations

• Student works half the time and observes half the time

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Advantages for students:

• Completes observation

• Gives insight into the “business”

• Is an advantage when applying to grad school or for a job

• Gives student a “foot in the door”

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Advantages for the program:

• Lots of free labor to greatly reduces support costs

• Level of skills are usually high

• Chance to select future employees

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True or False?

• Progress will generally be faster with intensive therapy.

• Progress will be faster with therapy as needed and intensive practice.

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Clinical Support

• Clinical “extenders” (SLPAs, students, parents/family members) should provide practice to expand patient’s to insure carry-over

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Theories of motor learning and motor memory

• Speech requires motor movement that is fast, complex, automatic and effortless

• This is accomplished by motor learning and motor memory

102



• Motor learning is dependent on:• instructions,

• trial and error, and

• feedback

• Motor learning is what needs to be done in therapy 103



• Motor memory is dependent on practice

• Develops the automaticity of the movement and ultimate “carry-over”

• Motor memory (through practice) should be done primarily at home, and not in the therapy session

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Practice is not going on at home if the parent doesn’t know:

• …the name of the child’s SLP, or

• …what the child is working on in speech therapy

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• Practice results in brain reorganization due to neural plasticity

• Practice is necessary for learning to perform all complicated motor movements and sequences without conscious thought, for example:

• Ballroom dancing: salsa

• Sports: shooting a basketball

• Playing an instrument: piano

• Speech106


• Speech therapy is like piano lessons…If you just go for the lesson but don’t practice at home, you don’t learn to play the piano

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Language learning also requires instructions, study and practice

• Learning a second language requires instruction first, then study and practice

• Language therapy is the same

108


• SLPs should not provide “professional” services that nonprofessionals can do.

• We need to focus on only providing high level, specialize care.

• Practice and drill do not require professional services and should be done in the home.

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• We need to train and coach family members on how to work with the patient at home.

110


• The family must be part of the treatment team!

• The family needs to bring the patient to each appointment.

AND

• Work with the patient daily (whenever possible) at home.

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How do you accomplish that?

“Self-Management” in Medicine and Healthcare

• Methods by which patients with a chronic conditions can effectively take care of themselves

• Methods by which families can manage chronic conditions in their children

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Self-Management

“Feed a man a fish, and he’ll eat for a day;

teach a man to fish and he’ll eat for a lifetime.”

(Native American saying, author unknown)

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Self-Management

To engage families to work with the patient, it helps to use principles of self-management, including motivational interviewing

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Self-Management

Motivational interviewing (MI) is a part of self-management:

• Focuses on exploring and resolving ambivalence to change (i.e., I want to lose weight, but I don’t want to change my eating habits.)

• Determines what motivates the individual to facilitate a change

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Self-Management

With MI, determine and mitigate barriers to reaching success:, including:

• Transportation

• Child care issues

• Health issues

• Scheduling issues

• Financial challenges

• Communication issues 117

Self-Management

SLPs can use self-management to improve:

• Attendance of scheduled sessions, and

• Involvement of the parents/family in the treatment process

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Self-Management

Motivational interview and development of self-management results in:

• Improved outcomes with fewer sessions and lower costs

• Improved patient/family satisfaction

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Self-Management

Self-management:• Is an important part of patient-centered care and care

coordination• Serves as a partnership between healthcare providers and

patients/families • Helps people with chronic conditions manage their health (or

their child’s health) on a day-to-day basis120

Streamlining documentation Molly Thompson

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SLPs spend about 20% of their time on documentation*

Increasing efficiency can save time and cost to both the SLP and the consumer

* ASHA 2013 Health Care Survey

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Documentation : a “bottom-up” view

Producing efficient documentation begins with hardware and ends in the cloud

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Hardware that supports efficiency

Scanner Computer Fax: machine or onlineConsider dual side scanner need remote access?* Online: stores off-site*Scans large amounts need a PDF-WORD program?

consider on-line backup*file old reports by diagnosis/treatmentfor easy access/ templates

*know your HIPPA requirements 124

Develop templates to streamline all patient documentation in a way that meets the needs

of all customers• Yet is fast to generate and , therefore, less costly to produce

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Thoughts on documentation

is the required content present and applicableare abbreviations understandable/is

there a key?is the patient’s performance

accurately reflectedis the need for your specialty

evident

do the goals/note coincide with the diagnosis and treatment codes is communication between patient

and clinician presentif shared, could others understand

what happened during the evaluation/treatment and why?

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• Practice Management

Utilize ASHA resources

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More resources

- Asha Community: SIGS, SLP Private Practice

- Asha Advocacy:

ASHA State Advocates for Reimbursement (S.T.A.R.)

State Medicare Administrative Contractor (S.M.A.C.)

- Other organizations related to setting

- State speech-language-hearing associations

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Consider your audience

“A report is an act of communication between you and your reader”

Study Advice from University of Reading

What do the customers want, need and read?

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The Patient/Families

• need clear, concise language that addresses their concerns, your clinical impressions, a plan of treatment and estimate of the duration of services.

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Physicians

• More is not necessarily better.

• Reading and signing a patient’s treatment plan is a non-value added service for the physician. Create a document that is clear and succinct.

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The Payer

• The medical reviewer is looking for medical necessity, that the diagnosis and treatment codes and goals are compatible with this. That these items are clearly stated in the documentation and presented in the most efficient means possible.

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The Auditor

• Considers, among other things, that billing and service dates match, proper signatures and dates are present on needed documentation and that provisions for service were met according to the contracting agency.

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Reprinted with permission from the Alaska Speech-Language Hearing Association

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The SLP

• intake=evaluation = treatment plan = treatment = daily note

• A good SOAP note creates a detailed snapshot of the session that provides a framework for further treatment.

• Is the treatment understandable to others ?

• Is your expertise evident?

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Utilize readily available resources

ASHA Practice Portal136

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When is the documentation generated?

• Within session (Point of service)

• Outside session

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When point of service isn’t an option

• Maximizing in-treatment documentation for later generation of the daily note is a must.

• There may be an app for that! More apps are providing data and reports

• More test companies are creating on-line evaluations that generate reports

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Electronic Health Records (EHR)

• There is no single format used by all professionals or organizations; whatever format is used for clinical record-keeping should conform to federal, state, and local laws and adhere to specific facility standards. Clinical records should be consistent in format and style and use appropriate terminology, approved abbreviations, and correct diagnosis and procedure codes.

Cornett, B. S. (2006, September 5). Clinical Documentation in Speech-Language Pathology. ASHA Leader.

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EHR checklist

Documentation management

Billing

Customizable Templates for evaluation, treatment and SOAP

Does it require a sign off on the date the service was provided

PQRS support for Medicare Part B

Reminders for re-certifications

Schedule

Fax

Forward of previous note for editing

Good tech support

Price

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Future technologies

• Be an active participant in the development of evolving technologies that will impact the management of communication and swallowing disorders

• Provide feedback to developers of tests, EHR and apps on what you and your consumers need and want

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Q&A

• [email protected] (Nancy)

• [email protected] (Charlette)

• [email protected] (Ann)

• [email protected] (Becky)

• [email protected] (Molly)

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Evolving Roles for SLPs: Surviving and Thriving in a Transforming Health Care Environment

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