Introduction and Overview
This is Part Two of a two-part series that will provide guidance on the assessment and treatment of individuals who present with low-level cognitive functioning. Part Two will examine evidence-based practice methods for speech-language pathologists regarding the treatment of patients who present with low-level cognitive function due to new onset or progressive neurological conditions. The three primary clinical categories that I will be reviewing include dementia, traumatic brain injury (TBI), and stroke.
In my courses, I always start with regulation so that you have a foundational understanding of the regulations that guide the skilled services that we can provide. Much of what I will speak about in this course is readily available and publicly accessible. The two key areas are in the Medicare Benefit Policy Manual, Chapter 15, sections 220 and 230. That is where you will find regulation and guidance for the level of services for which we are able to provide care. Additionally, you may look into local coverage determinations to find guidance on services that are deemed reasonable and necessary for the area in which you are providing care.
The first area that I want to review deals with a regulation that went into effect back in 1987, and it was part of the Omnibus Budget Reconciliation Act, also known as OBRA. It laid the foundation for providing care in skilled nursing facilities (SNFs). It dramatically changed the way that skilled nursing facilities and the entire interdisciplinary team within them approached the provision of resident care. It also radically modified the nursing home regulation and survey process. The reason that I wanted to include this regulation in a training course for individuals with low-level cognitive function is that these individuals end up in a long-term care or a skilled nursing facility for a couple of reasons. One reason is that they have a new onset stroke or TBI, and due to the severity and their low-level functioning, they come to a SNF for a short course of rehab before returning to their prior functional status. Another reason is that some individuals have chronic, progressive neurological conditions such as dementia. They often end up in a skilled nursing facility for long-term care.
This regulation mandated that facilities “provide necessary care and services to help each resident” - look at the language here – “attain or maintain their highest practicable, physical, mental, and psychosocial well-being, and to ensure that the resident obtains the optimal improvement, or does not deteriorate within the limits of a recognized right to refuse care or treatment, and within the limits of their recognized pathology and the normal aging process.” I hope all SLPs will have a better understanding, after we are done, about the unique skillset that you are able to provide to residents as part of the treatment process to help them either improve, or maintain, or prevent deterioration. We are able to provide skilled treatment for three areas. We not only help patients improve; we can also help them maintain, and prevent further deterioration. In my clinical experience, I find that therapists do not always take credit for that skillset that they have, and the level of care that they may be able to provide to an individual that no one else in their setting can. It is also important to be cognizant that this regulation is for the entire interdisciplinary team. This is not something that applies only to nursing, or to certified nursing assistants (CNAs); it is important as an SLP to advocate for these regulations, because in certain settings they may be unaware that this regulation applies to the whole team. You could use this for advocacy purposes and education about the services that you are providing.
I often get the question, “If someone has a chronic condition can I assess them, and should I treat them afterward?” This next regulation, from the Medicare Benefit Policy Manual, can answer that. This is Medicare language. I did not edit this in any way. It states that rehab therapy “may be needed, and furthermore improvement in a patient's condition may occur, even when a chronic, progressive, degenerative, or terminal condition exists. For example, a terminally ill patient may begin to exhibit self-care, mobility, and/or safety dependence requiring skilled therapy services. The fact that full or partial recovery is not possible does not necessarily mean that skilled therapy is not needed to improve the patient's condition, or to maximize those abilities. The deciding factors are always whether the services are considered reasonable, effective treatments for the patient's condition, and require the skills of a therapist, or whether they can be safely and effectively carried out by non-skilled personnel.” So when you are providing treatment, which of course follows a comprehensive assessment such as we addressed in Part One, you need to think to yourself, “Is there a level of care in regards to treatment that I can provide to this patient, that no one else can provide?”
Here is a great question from the audience; let’s take a moment to answer it. “Do these same guidelines exist for outpatient treatment of cognitive impairments in chronic conditions; i.e. dementia?” The answer is yes, absolutely. The regulations that I am referring to are from chapter 15, which is actually Medicare Part B regulation, and most payers will follow suit. Medicare typically has the most stringent regulations. So yes, these regulations apply to that Part B outpatient, chronic, progressive neurological dementia-based population that you are seeing. If you are in an outpatient center that is actually providing that level of care, that is outstanding. It is great to hear that people are reaching out and providing that level of care in the community; it is a very positive sign.
Determining Skilled Need
How do I determine, when I am treating, if the services are skilled? What are the criteria? 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, 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. 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 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.
Plans of Care – Restorative vs. Maintenance
There are two levels of care that we can provide when treating individuals across the board, including those with low-level cognitive function. We are either treating to restore, or we are treating to maintain. When we talk about “maintaining,” I want everyone to have an understanding of what the new guidelines are for treating stroke, and that we are now looking at that as a chronic condition.
Restoring function. Most therapy providers know and understand, and that is how to rehabilitate somebody. When you are treating, be clear in your documentation about the services that you are providing. The definition of rehab/restorative therapy “includes services designed to address recovery or improvement in function, and, when possible, restoration to a previous level of health and well-being” (i.e., PLOF, or Prior Level of Function). We addressed this dynamic in Part 1 of this series. Your plan should describe objective measures that, when compared, show improvements in function. For low-level individuals, if it is a new onset stroke or TBI, we are hoping to restore to a certain level.
Maintaining function. We also have the opportunity as skilled speech-language pathologists to treat individuals to maintain their level of function. Again, this is Medicare language, not my own language. I took it directly from the benefit policy manual. A skilled maintenance program means “a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to disease or illness.”
What are some examples of this? You may establish a plan of care to improve attention to task at meals with development of a functional dining program. You may establish a plan of care and treat for improved environmental awareness via use of signage. Additionally, you may be treating someone in both manners. You may have an individual with a new stroke that you are treating for lower level language skills, while at the same time, you are working on maintenance of higher-level skills. You can treat both at the same time. Depending on the severity of a new insult, we may be restoring to a certain level, but also continuing to provide care to maintain.
The important thing that you need to consider is that the services cannot be repetitive in nature on a day-to-day basis. Let’s say you are treating a patient to maintain, and as part of that maintenance program, you are using visual cues or signage in the environment to tap into procedural memory. Anyone who works with patients with dementia know that procedural memory - things that we learn by doing, such as reading, writing, playing the piano, riding a bike - is our best friend. So if we tap into signage and reading, and we are implementing signage in the environment to improve someone's ability to perform oral care independently, and we go in every day and review those steps in the same manner, then that would not be skilled maintenance. But if there are adjustments or alterations to the cuing system, or training opportunities as part of that maintenance plan, then that is skilled maintenance.
The final piece, and in my experience, the most untapped piece for speech-language pathologists, is this idea of preventing further deterioration. If you are able to provide care to somebody, and she is actually declining, but you are preventing a greater decline, then you can provide care for that individual. This is something that many SLPs do not have an understanding of; they are not aware that that can be part of their skillset. I hope all of you recognize that skillset after taking this course, and if you are in a setting where you have the opportunity to treat someone to prevent deterioration, that you take the opportunity to do so.