On The Pulse: The Push to Preserve Clinical Judgment Heated online discussions about growing productivity pressures in long-term care facilities have spurred a grassroots campaign to change policies. On the Pulse
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On the Pulse  |   February 01, 2014
On The Pulse: The Push to Preserve Clinical Judgment
Author Notes
  • Janet Brown, MA, CCC-SLP, is ASHA director of health care services in speech-language pathology. ·jbrown@asha.org
    Janet Brown, MA, CCC-SLP, is ASHA director of health care services in speech-language pathology. ·jbrown@asha.org×
  • Monica Sampson, MA, CCC-SLP, is ASHA associate director of health care services in speech-language pathology. ·msampson@asha.org
    Monica Sampson, MA, CCC-SLP, is ASHA associate director of health care services in speech-language pathology. ·msampson@asha.org×
Article Information
Special Populations / Older Adults & Aging / Healthcare Settings / Practice Management / Professional Issues & Training / ASHA News & Member Stories / On the Pulse
On the Pulse   |   February 01, 2014
On The Pulse: The Push to Preserve Clinical Judgment
The ASHA Leader, February 2014, Vol. 19, 34-35. doi:10.1044/leader.OTP.19022014.34
The ASHA Leader, February 2014, Vol. 19, 34-35. doi:10.1044/leader.OTP.19022014.34
Concern for seniors, a desire to help them maximize their functional abilities, and a passionate interest in understanding the impact of aging have drawn speech-language pathologists to the long-term care setting. But complaints of employer pressures to increase productivity and billing at the expense of clinical judgment have recently resulted in a groundswell of protests from vocal SLPs.
The crescendo of concern voiced on social media and in the ASHA Community arose from a group of ASHA members discussing the challenge of working in skilled nursing facilities. They began a letter-writing campaign to ASHA and several state licensing boards to describe their experiences regarding several key issues: productivity pressures overriding clinical judgment (such as pressure to limit evaluations to 15 minutes); hiring clinical fellows without sufficient support; and providing insufficient evaluation and treatment materials. The discussion extended to various ASHA Community forums, including SLP Health Care and Special Interest Groups 2, Neurophysiology and Neurogenic Disorders, and 15, Gerontology.
On Dec. 12, ASHA staff held an online chat, “Employment Issues in Long-Term Care: Productivity, Ethics and Fraud”, to provide a forum for discussing these issues. More than 200 participants provided 650 comments during the 90-minute session—far more than could actually be posted during the chat. Chat participants posted personal experiences like these:
  • “I wind up working 10-20 hours a week ‘off the clock’ to get the patients treated and my paperwork done. But when residents refuse [treatment] or are out of facility, I am supposed to go home early.”

  • “I’ve been told that if my evals consistently exceed 15 minutes, I would not be with the rehab company very long.”

  • “My company requires 90 percent productivity, and I have been threatened with termination multiple times for maintaining 70-80 percent productivity for the week. Also, when Medicare rules are cited, I have had employers suggest that the employee may be terminated.”

  • “I felt completely unprepared to work in an SNF as a CF [clinical fellow]. The actual therapy was fine, however dealing with RUG [resource utilization group] levels, productivity and floating to several facilities was incredibly stressful.”

  • “We are told to advocate for ourselves but most places won’t listen. They dock our pay or threaten to fire us or don’t give us raises. How can I advocate effectively if my job is on the line? I know that I am not alone on this.”

Some commenters called for the formation of a union or a rating system for employers. (In a subsequent post, a member recommended www.glassdoor.com, which provides this service.) Other commenters expressed surprise or relief that their employers did not make unreasonable productivity demands or limit their clinical autonomy in performing evaluations.
According to ASHA’s 2012 member counts, 10 percent of certified SLPs—approximately 13,000 people—work in residential health care facilities. Although SLPs report a troubling, increased focus on increasing revenue across all health care settings, ASHA’s biennial health care survey cites a larger percentage of SLPs in SNFs indicating that they felt pressured by an employer or supervisor (see “SLPs Feel Continued Pressure on Clinical Judgment,” The ASHA Leader, Oct. 1, 2013).
And not only SLPs are questioning employers’ motives in long-term care. Service delivery and billing practices in skilled nursing facilities have been the focus of national conversation and ongoing investigations at the Office of the Inspector General in the U.S. Department of Health and Human Services.
ASHA has provided recommendations about how to address these issues (see “When Your Employer Makes Unethical Demands,” The ASHA Leader, Feb. 1, 2013, and developed resources to assist members in such situations. Most recently, ASHA’s website added Medicare guidelines for SLPs in SNFs to make Medicare regulations more accessible to SLPs.
As a follow-up to the online chat, ASHA 2013 President Patty Prelock sent a letter to the presidents of the American Occupational Therapy Association and the American Physical Therapy Association— whose members are experiencing similar pressures—asking for an opportunity to discuss the situation to identify potential actions that could reduce stress on clinicians and foster patient-centered care. ASHA also plans to propose opening a dialogue with trade associations for the long-term care industry.
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February 2014
Volume 19, Issue 2