Why We Need to Practice at the Top of the License To demonstrate our true value and effectiveness, we need to maximize time spent delivering services we are uniquely qualified to provide. From My Perspective
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From My Perspective  |   February 01, 2018
Why We Need to Practice at the Top of the License
Author Notes
  • Lemmietta McNeilly, PhD, CCC-SLP, is ASHA chief staff officer for speech-language pathology. lmcneilly@asha.org
    Lemmietta McNeilly, PhD, CCC-SLP, is ASHA chief staff officer for speech-language pathology. lmcneilly@asha.org×
Article Information
Professional Issues & Training / From My Perspective
From My Perspective   |   February 01, 2018
Why We Need to Practice at the Top of the License
The ASHA Leader, February 2018, Vol. 23, 10-11. doi:10.1044/leader.FMP.23022018.10
The ASHA Leader, February 2018, Vol. 23, 10-11. doi:10.1044/leader.FMP.23022018.10
Audiologists and speech-language pathologists consider a variety of service-delivery options and determine the best strategies for an individual and their family based on the setting and life conditions.
The continuum of service delivery includes:
  • What: Options along the continuum such as assessment, intervention, consultations with other professionals; management of indirect services provided by family members; and the individual’s self-management.

  • How: Services provided in a variety of formats, including in-person or via telepractice.

  • Where: Diverse settings including natural settings (for example, classrooms, homes and communities), and various education and health care facilities, offices and clinics.

  • Who: Services provided by licensed/certified audiologists and speech-language pathologists or appropriately supervised/mentored support personnel, graduate students and clinical fellows.

In providing this continuum of services, it is critical that we practice at the top of our license. What does this mean? It includes assessing individuals, providing skilled intervention, consulting with colleagues regarding functional goals and treatment options, and supervising support personnel (audiology assistants and speech-language pathology assistants), students, and clinical fellows. It also means providing education or professional development on challenging and emerging practice strategies, and working with clients and their families on self-management.
Audiologists and SLPs should strive to “practice at the top of the license” and to educate individuals in self-management strategies. Across the globe, there are not enough audiologists and SLPs to meet the needs of each individual living with communication disorders. Additionally, it takes time for behaviors to change and time to practice new skills. Therefore, when we focus attention on the clinical activities that require our unique knowledge, skills and attitudes, we facilitate functional outcomes in a cost-effective manner.

When we focus attention on the clinical activities that require our unique knowledge, skills and attitudes, we facilitate functional outcomes in a cost-effective manner.

Employing our skills
Audiologists and SLPs practicing at each level/setting across the continuum of care settings (for example, acute care, inpatient rehabilitation, skilled nursing, home health, outpatient, early intervention, schools and private practice) need to determine which services are most beneficial and valuable to an individual. Variations in payment methods in different settings will influence service-delivery options.
Alex Johnson, provost and vice president at the MGH Institute of Health Professions, used this “practice at the top of the license” wording during his presentation at the Researcher-Academic Town Meeting —“Preparing Audiologists and Speech-Language Pathologists to Provide Value-Based Services in the New Economic Climate”—at the 2012 ASHA Convention.
The phrase was also used in the December 2013 final report of the ASHA Ad Hoc Committee on Reframing the Professions. The committee’s report, “Reframing the Professions of Speech-Language Pathology and Audiology,” specifically states on page 10, “Work at top of license: SLPs should engage in only those patient-care activities that require their level of expertise and skill.” The idea behind this mantra is that audiologists and SLPs should limit our professional activities to those services that are within our scope of practice and are considered skilled.
Changes are on the horizon, which include reporting treatment outcomes, different payment models, and changes in Medicaid programs. These changes will increase our accountability for outcomes, cost-effectiveness and efficiencies. This trend is driving the need to use a range of service-delivery options and determine the most appropriate service provider to deliver each aspect of service: in other words, to practice at the top of the license. The approach empowers audiologists and SLPs to maximize the time they spend delivering services they are uniquely qualified to provide and may include collaborating with extenders to provide services in the most cost-effective manner.
Strategies to successfully practice at the top of the license may require new ways of thinking and working by:
  • Delegating responsibilities that do not require professional interpretation and judgment.

  • Enhancing supervision and management skills.

  • Demonstrating and articulating our own unique knowledge and skills (value) and how we can contribute to teams.

Audiologists and SLPs should engage in only those patient/student/client care activities that require their level of expertise and skill. Practicing at the top of the license includes all aspects of service delivery:
  • Assessment.

  • Skilled intervention.

  • Consultations with colleagues regarding functional goals and treatment options.

  • Delegation of tasks (supervision/mentoring), which can apply to clinical fellows, students, support personnel (such as speech-language pathology/audiology assistants), technicians, family members and volunteers.

The approach empowers audiologists and SLPs to maximize the time they spend delivering services they are uniquely qualified to provide.

Functional goals and service delivery
The paradigm shift to person-centered care facilitates use of the International Classification of Functioning, Disability and Health (ICF) framework to develop individualized functional goals set out by the World Health Organization in 2001. The ICF provides a rubric for an individual’s functioning and disability in the context of activities and social roles in everyday life. The ICF addresses functioning as a component of health and is not based on etiology or “consequence of disease.”
The World Health Organization defines “health” as the complete physical, mental and social functioning of a person and not merely the absence of disease. In this definition, functioning as classified in the ICF is an essential component of health.
Targeting functional goals for our patients/students/clients is a component of practicing at the top of the license, as it:
  • Maximizes outcomes, because treatment of impairments alone may not lead to functional improvement or be meaningful to the individual.

  • Optimizes the individual’s potential to engage in meaningful activities following discharge.

  • Increases engagement with individuals and their families.

  • Demonstrates the value of skilled services to payers.

The continuum of service delivery includes several options:
  • Using extenders such as rehab technicians, family members, community workers and SLPAs and audiology assistants.

  • Consultations with, for example, other professionals and individuals and families.

  • Varied service-delivery models, such as intensive treatment, more frequent sessions scheduled in blocks, and varying location, frequency, and length of sessions.

  • Telepractice, using telecommunications to deliver audiology and speech-language pathology services at a distance.

  • Self-management—empowering individuals to improve their functioning based on strategies designed by clinicians.

  • Interprofessional practice (IPP) and interprofessional education (IPE), which prepare practitioners to competently engage in IPP. The World Health Organization in 2010 defined IPE as situations in which “…two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes.” It defined IPP as situations in which “…multiple health workers from different professional backgrounds provide comprehensive health services by working with patients, their families, caregivers, and communities to deliver the highest quality of care across settings.”

Numerous changes in health care, schools and communities create opportunities for audiologists and SLPs to use different service-delivery options. These options enhance service delivery across the continuum and demonstrate value and functional outcomes for individuals. A significant option for practitioners to consider is “top of the license” practice.
Looking for More?

Check out these resources for more information on the World Health Organization, health care reform, service delivery, interprofessional education and practice, and other issues related to practicing at the top of the license.

“Health Care Reform and Speech-Language Pathology Practice,” in the August 2010 issue of The ASHA Leader

The World Health Organization’s International Classification of Functioning, Disability, and Health

The World Health Organization’s Framework for Action on Interprofessional Education and Collaborative Practice

Executive Summary Report from the ASHA Health Care Summit

Final Report from ASHA’s Ad Hoc Committee on Reframing the Professions

ASHA’s professional issues statement, “Roles and Responsibilities for School-based SLPs”

“Enhance Service Delivery Across the Continuum of Care to Increase Value and Access to Services” (ASHA Strategic Pathway to Excellence, Objective #4) webinar

ASHA webpage, “Service Delivery Resources”

“Preferred Educational Future in CSD,” Alex Johnson’s 2012 ASHA Convention presentation

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February 2018
Volume 23, Issue 2