ASHA’s Strategic Pathway and You: Focus on Objective 4 Did you know ASHA has a roadmap for achieving the association’s vision and mission? The association’s “Strategic Pathway to Excellence” identifies eight strategic objectives to do just that through the year 2025, when ASHA will be 100 years old. The Envisioned Future document describes this centennial vision. Members are integral ... ASHA News
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ASHA News  |   January 01, 2016
ASHA’s Strategic Pathway and You: Focus on Objective 4
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Swallowing, Dysphagia & Feeding Disorders / Professional Issues & Training / ASHA News & Member Stories / ASHA News
ASHA News   |   January 01, 2016
ASHA’s Strategic Pathway and You: Focus on Objective 4
The ASHA Leader, January 2016, Vol. 21, 56-57. doi:10.1044/leader.AN1.21012016.56
The ASHA Leader, January 2016, Vol. 21, 56-57. doi:10.1044/leader.AN1.21012016.56
Did you know ASHA has a roadmap for achieving the association’s vision and mission? The association’s “Strategic Pathway to Excellence” identifies eight strategic objectives to do just that through the year 2025, when ASHA will be 100 years old. The Envisioned Future document describes this centennial vision.
Members are integral to working toward the strategic objectives and realizing the Envisioned Future: 2025 outcomes. Each month, the Leader examines one of the objectives and how a member is addressing it.
Objective 4: Enhance service delivery across the continuum of care to increase value and access to services.
Lemmietta McNeilly, ASHA chief staff officer for speech-language pathology and staff “owner” of the effort, describes the objective:
“This objective seeks to empower members to increase access to audiology and speech-language pathology services and to communicate in plain language the value of those services to payers, consumers and colleagues. To help with this, ASHA is planning initiatives and developing resources in the areas of practice at the ‘top of the license,’ appropriate use of support personnel, use of the International Classification of Functional Disability and Health, telepractice delivery options, and clinical decision-making across varied areas of practice.”
Practicing at the top of the license is a particularly important part of this objective, as explicated by Alex Johnson, provost and vice president for academic affairs at the MGH Institute of Health Professions in Boston:
“The contemporary practice of speech-language pathology is a team sport. Families, SLP assistants, other health professionals and a variety of community partners are all critical to achieving best outcomes in communication and swallowing. Additionally, new technology applications that extend treatment beyond the therapy room are increasingly available. While SLPs have typically involved others in the treatment of those we serve, the escalating discussion of cost and efficiency has called even more attention to related critical practice issues.
“Thus ‘top of the license’ is a useful term to consider the evolving role of the clinician relative to the patient and to the team of providers and supporters that surrounds the patient. What are the activities and areas of practice that uniquely require the critical thinking, decision-making, planning and clinical abilities of a skilled provider? These choices have to be made with regard to the specific patient, always with the best interest of that patient at the center of the discussion.

“What are the activities and areas of practice that uniquely require the critical thinking, decision making, planning and clinical abilities of a skilled provider?”

“We need to acknowledge that the most expensive aspect of speech and language intervention is typically the cost of the SLP’s time. Increasingly, there is evidence in the literature that desirable outcomes may be achieved when some services are provided by trained ‘extenders’ who may be SLPAs, nursing assistants, family members and so forth, yet these innovations receive relatively little attention in most practice settings. When one considers the cost of our services as a major impediment to access for many clients, imagine the impact of cutting the cost of service delivery by 10 to 20 percent per patient—using an extender or technology to replace the time of the skilled and experienced SLP.
“Caution needs to be provided, of course, as replacing the required skills and knowledge of the audiologist or SLP in service delivery could have a negative impact on both outcomes and cost. Thus, judicious use of alternative service-delivery models is essential and required for ethical reasons. In the short term, clinicians might advance this discussion by considering a few suggestions:
  • Use demonstrated approaches that have the opportunity to reduce time in treatment or to allow nonessential services to be provided by others (or technology).

  • Include family members or other communication partners, when feasible and appropriate, in treatment from day one.

  • Talk with administrators about increasing access to appropriate technical and personnel resources to reduce the burden of paperwork, materials preparation and other activities that could be handled easily by trained support personnel.

  • Consider effective ways to train others to do critical but nonskilled tasks that may be essential to patient, student or client progress.

  • Increase awareness among students in audiology and speech-language pathology about working at the top of their license as they learn about service delivery.”

Several initiatives at MGH and the MGH Institute of Health Professions provide examples of top-of-the-license approaches in patient care.
Carmen Vega-Barachowitz, director, Department of Speech, Language and Swallowing Disorders & Reading Disabilities, Massachusetts General Hospital; assistant professor, Communication Sciences and Disorders, MGH Institute of Health Professions
“At MGH, SLPs are engaged in clinical decision-making, team collaboration and maintaining relationships with patients and families. A thorough analysis of these aspects of care helps SLPs discern tasks that fall within our professional responsibilities from those that could be performed by an unlicensed individual or volunteer. Determining which tasks warrant delegation is one of the most important steps in the process.
“In the outpatient setting, we have six teams of clinicians specializing in either communication or swallowing with adult or pediatric patients. The various teams have designed prioritization systems to ensure patients are seen in a timely manner, according to their needs. As part of the prioritization system, the nonclinical staff members have been trained to review new referrals so that triaging and prioritization functions have been shifted from the SLP to a nonclinical trained individual.
“The SLPs are available for consultation if questions arise, but the elimination of these functions from the SLPs’ responsibilities has allowed them to spend more time with clinical care and documentation.

“Nonclinical staff members have been trained to review new referrals so that triaging and prioritization functions have been shifted from the SLP to a nonclinical trained individual.”

“We are also implementing another process to ensure SLPs are working mostly at the top of the license. A team comprising a pediatric SLP, a pediatric gastroenterologist, a child psychologist and a dietician conduct pediatric feeding-swallowing team evaluations. Until recently, the team evaluated three children and their families per afternoon, but the team felt that more patients/families could be seen with increased efficiency. We began our quality improvement project by examining the process involved prior, during and after the clinical evaluation session.
“As a result, it was determined that greeting the patient, collecting the case history, cleaning and preparing the room for the next patient/family, and escorting out the patient/family at the end of the session were tasks that could be delegated to a student volunteer or nonclinical support staff. We also identified that by having two rooms available simultaneously, the number of patients scheduled could potentially double. Nonclinical staff clean and prepare one room, while the team of professionals conducts the evaluation or follow-up visit in another room.”
Working at the top of a clinician’s license has great potential to amplify the impact of the clinical services. An example is increasing the time a client spends engaging in goal-directed practice or receiving feedback from team members, including the family.
Working at the top of one’s license also has the potential to expand access to audiology and speech-language services, as some portion of clinicians’ time could be reallocated to seeing additional people who need services. In the face of a growing population and the longstanding shortages of audiologists and SLPs, it makes sense to engage other professionals, extenders and technology in service delivery, particularly if this allows clinicians to spend more time focusing on the areas they are uniquely qualified to perform.
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January 2016
Volume 21, Issue 1