speech therapy in nursing meaning

The Role and Impact of Speech Therapy

by Regency Staff | May 3, 2024

Speech is one of the most fundamental forms of human communication, allowing us to express thoughts, emotions, and desires. However, for some individuals, communicating through speech can be a challenge due to various factors such as developmental delays, neurological conditions, or injuries. This is where speech therapy plays a pivotal role, offering tailored interventions to help individuals overcome communication barriers and unlock their full potential.

Understanding Speech Therapy : Speech therapy, also known as speech-language pathology, is a specialized field aimed at assessing, diagnosing, and treating communication disorders. Speech-language pathologists (SLPs) are trained professionals who work with people of all ages, from infants to seniors, addressing a wide range of communication difficulties.

The scope of speech therapy is broad, encompassing various aspects of communication, including speech production, language comprehension, social communication, fluency, voice, and cognitive-communication skills. SLPs employ evidence-based techniques and strategies to target specific communication goals, tailored to each individual’s needs.

Common Conditions Treated: Speech therapy can address a multitude of communication disorders and challenges, including:

Articulation Disorders: Difficulties with speech sound production, such as substituting, omitting, or distorting sounds.
Language Disorders: Challenges with understanding language (receptive) or expressing thoughts and ideas (expressive).
Stuttering: Disruptions in the fluency of speech, characterized by repetitions, prolongations, or blocks of sounds or words.
Voice Disorders: Problems with the quality, pitch, or volume of the voice, often resulting from vocal cord abnormalities or misuse.
Aphasia: Impairments in language processing and production typically caused by stroke or other brain injuries.
Autism Spectrum Disorder (ASD): Speech therapy can help individuals with ASD improve communication skills, including language development and social interaction.
Cognitive-Communication Disorders: Difficulties with memory, attention, problem-solving, and other cognitive functions affecting communication.

The Therapy Process: Speech therapy begins with a comprehensive assessment to identify the specific communication challenges and establish baseline skills. Based on the assessment findings, the SLP develops an individualized treatment plan, setting measurable goals and outlining intervention strategies with their doctor .

Therapy sessions may involve a variety of activities, exercises, and techniques tailored to target areas of need. These could include:

Articulation drills and exercises to improve speech sound production.
Language-based activities such as storytelling, vocabulary building, and comprehension exercises.
Fluency-shaping techniques and strategies to manage stuttering.
Voice therapy exercises to improve vocal quality, resonance, and breath support.
Social communication interventions focusing on conversation skills, nonverbal cues, and pragmatic language.
Cognitive-communication tasks to enhance memory, attention, and problem-solving abilities.

In addition to direct therapy sessions, speech-language pathologists often collaborate with other professionals, including educators, physicians, psychologists, and occupational therapists, to ensure a holistic approach to intervention.

The Benefits of Speech Therapy: Speech therapy offers numerous benefits beyond improved communication skills. For individuals with communication disorders, it can enhance social interactions, academic performance, vocational opportunities, and overall quality of life. By addressing communication challenges early and effectively, speech therapy can empower individuals to participate more fully in their communities and achieve their personal and professional goals.

Furthermore, speech therapy is not solely focused on the individual receiving treatment. It also provides valuable support and education for family members and caregivers, equipping them with strategies to facilitate communication and maximize progress outside of therapy sessions.

Conclusion: Speech therapy is a transformative field that empowers individuals to overcome communication barriers and reach their full potential. Whether addressing developmental delays, neurological conditions, or acquired injuries, speech-language pathologists play a critical role in enhancing quality of life and promoting meaningful participation in society. Through evidence-based interventions, tailored treatment plans, and a holistic approach to communication, speech therapy unlocks the power of speech for individuals of all ages, enabling them to connect, express, and thrive.

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5 Top Tips to Thrive as an SLP in the Skilled Nursing Setting

By Julia Kuhn, MS, CCC-SLP

on September 11, 2018

Categories: Cognition , Dysphagia , Geriatrics , Motor Speech , Occupational Therapy , Patient Engagement , Speech Pathology

Speech-language pathologists (SLPs) often work at skilled nursing facilities (SNFs), providing short-term rehab care and ongoing treatment for long-term care residents. Some of the SLP treatments most frequently seen in the SNF setting include care for dysphagia, cognitive-linguistic functioning, and speech-language deficits.

As a traveling speech-language pathologist, I’ve worked in more than 40 SNFs. Here, I offer my top tips to thrive as an SLP in a SNF.

1. Be Flexible

In the fast-paced medical field, things don’t always happen how or when you want them to. You need to be flexible when it comes to changing your plans and your schedule based on the needs of the people in your care.

For instance, one day you might need to reschedule a treatment time at the last minute. On another, you might need to change the plan for a treatment session to focus on cognitive instead of language goals.

Understanding this dynamic and being flexible with treatments and your schedule will help you better help those within your care.

2. Be a Team Player

SNFs are comprised of a large staff in a variety of different roles. From the dietary team to the building administrator , everyone plays an important part in keeping the facility running smoothly. Get to know not only the rehab team, but the many other teams that work in the SNF as well. Take the time to introduce yourself to the dietary department, housekeeping, and nursing staff.

Working as a team can improve overall outcomes for the people living in the facility. Plus, lending a helping hand to your coworkers will not go unnoticed, and if you need help in the future, you will be more likely to receive it.

3. Take Advantage of Continuing Education

When you work in a SNF, you provide care to a large and diverse group of people. One day you might work with a patient who has memory loss, and the next you might assist someone who has had a stroke or head and neck cancer . Keep your skills current by subscribing to educational resources like MedBridge.

It’s easy to fall into the rut of thinking you don’t have time for your continuing education, especially after a busy day. But many MedBridge courses are short, often only one to two hours, making them easy to fit in your schedule. Plus, the range of topics is so diverse that you can usually find a course to help you address a new set of needs or a particularly challenging circumstance.

Not a subscriber yet? Take a look through MedBridge’s courses on evaluation and treatment related to dysphagia , cognitive communication , and speech-language deficits . I enjoyed the courses on dysphagia evaluation and treatment, and I’ve been able to transfer the skills I learned online to my treatment sessions.

4. Create Resident-Centered Plans of Care

When you are completing an evaluation and developing a plan of care, let the residents’ goals guide your treatment. During your evaluation, make sure to find out what their goals are and continue to check in during treatment sessions. Selecting a highly motivating goal will improve participation and attention in treatment—particularly when you are working with someone who has dementia or memory loss.

As you complete tasks in treatment, let the resident know how this treatment is impacting their overall plan of care and progress toward their goals. It’s also helpful to tailor short-term goals to match the resident’s long-term goals. For instance, if the person you are treating has a long-term goal to eat steak, you can create a short-term goal of eating a moist, minced solid, like ground beef.

5. Use Your Materials to Address Multiple Goals

One of the challenges of working in a SNF is that you might not have a dedicated speech office on site or access to (or the budget for) a variety of materials. For this reason, SLPs in this setting often find themselves conducting treatment sessions in residents’ rooms or on tables in a therapy gym.

This can be addressed by gathering a (literal) handful of materials that can be easily carried with you throughout the day. These same materials can work for multiple residents and multiple goals. Workbooks, an iPad, picture cards, and decks of playing cards are all useful items that can be used to work toward a variety of goals. It’s helpful to look at your materials in advance and determine ways in which you can use the same materials to address multiple goals. Personally, I keep an aphasia workbook , deck of cards, and an iPad in my SLP toolkit when I work in the SNF setting.

Now that you know these tips, I urge you to put them into practice at your SNF. Be flexible with your schedule and take the time to introduce yourself to somebody new on the team—or take some MedBridge courses to further your clinical expertise!

Julia Kuhn, MS, CCC-SLP

Julia Kuhn, MS CCC-SLP is a speech-language pathologist specializing in adult neurogenic rehab. She has been a traveling therapist since 2010 and provides resources to other traveling therapists through The Traveling Traveler .

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Speech and Language Therapy

Speech and language therapy or pathology is a type of health care that addresses communication and swallowing disabilities and issues. Professionals in this field are highly-trained experts in working with both children and adults who struggle to speak, communicate, comprehend or use language, or eat and drink because of any number of conditions and disabilities.

The care that speech and language therapists provide is important in many ways. For children who cannot swallow easily, they help ease eating and drinking. For adults with impaired communication from illnesses or accidents, they can help restore speaking. And for kids with disabilities and speech difficulties, they can aid in making communication more effective and easier. Be sure to choose a therapist who is licensed and comes recommended by a doctor or previous patients.

What is Speech and Language Therapy?

Speech and language therapy, also sometimes referred to more simply as speech therapy or as speech and language pathology, is a type of therapy that helps patients of any age who struggle with communication, speaking, swallowing, eating, and drinking. Speech and language therapists or pathologists evaluate, diagnose, and treat people with communication, cognitive, voice, and swallowing disorders or conditions that affect communication, speaking, and swallowing.

A speech-language therapist is an allied health professional, skilled health care with specific training. These therapists have earned undergraduate degrees as well as advanced graduate degrees in speech and language pathology. They are licensed by the state they practice in and are often certified by professional organizations like the American Speech-Language-Hearing Association.

Childhood Disorders Treated with Speech Therapy

There are many conditions that can be treated with speech and language therapy, including those that affect adults, children, or both. Many of these are more common in children, who can improve the ability to communicate or swallow. Some of the conditions that may lead a child to need speech and language therapy include:

Articulation disorders, which cause a child to mispronounce words or sounds.
Resonance and voice disorders that cause issues with pitch, quality, and volume.
Fluency disorders, like stuttering.
Expressive disorders, which cause a child to have difficulties with expressing or using language.
Receptive disorders that make processing and understanding language difficult.
Cognitive disorders that affect communication.
Dysphagia, and other swallowing or feeding disorders that make eating and drinking difficult.
Mental illnesses, behavioral disorders, and developmental disorders that interfere with the ability to communicate.

Speech pathologists guide these sessions with activities and exercises that are designed to help the patient meet their goals. They also evaluate patients on an ongoing basis to assess progress and then adjust the treatment as needed. Therapists work with parents and patients and teach them exercises they can use at home to further improve communication.

Speech Therapy for Adults

When speech and language therapists work with adults, it is often for rehabilitation or to improve the communication or swallowing symptoms caused by illnesses, accident, or progressive illnesses. For example, a stroke may leave someone with speech difficulties and therapy can help restore some or all of the ability to speak and communicate. Other illnesses and conditions that may require speech therapy include Parkinson’s disease, Alzheimer’s disease, brain or throat cancer, and brain injuries.

Adults may also need speech therapy for voice and communication disorders that were not treated in childhood, like stuttering or expressive disorders that are not so severe as to make communication impossible. Mental illnesses, learning disabilities, and behavioral disorders may also require treatment with speech and language therapy to improve communication.

What Happens in Speech Therapy Sessions?

Speech and language therapy sessions include a variety of elements and differ based on the needs of the individual patients. The first thing a pathologist does with a patient is a thorough evaluation to assess their needs and abilities. They also can make a diagnosis at this point, which can then lead to the development of goals and a treatment strategy. Elements of treatment vary depending on the patient, but may include:

Teaching the patient how to make specific sounds.
Using games and toys with children to help improve speech.
Guiding patients to develop vocabulary and sentence structure.
Using exercises to strengthen muscles used to swallow or speak.
Working with patients and their families about how to work on goals at home and how to improve communication.
Counseling patients with emotional or behavioral issues to help improve communication.

Where Speech and Language Therapy is Offered

Speech and language therapists work in many different settings. Because they often work with children, speech and language pathologists are often found in schools and pediatric units in hospitals, clinics, and medical centers. They also work in private practices, in community health clinics and programs, in prisons, in children’s homes, in nursing homes, and in speech and language clinics. They may work along with other health professionals as part of a multi-disciplinary team that helps patients with a variety of strategies.

How to Get High Quality Speech and Language Care

To ensure that you or your child gets the best quality of care for speech or swallowing conditions and symptoms, it is important to take care when choosing a therapist. Getting a referral from your physician or pediatrician is a great place to start, but also be sure to check the qualifications of the therapist you choose. The therapist should be licensed and associated with a professional organization. You may also want to get references to determine if past patients were satisfied with the results. Look specifically for qualifications and references that are relevant to your or your child’s specific issues and goals.

Speech and language pathology is an important type of care. For people who struggle to communicate, functioning in school, at work, and in relationships with other people can be very challenging. These therapists are trained to help individuals communicate better and in doing so also improve their quality of life measures. Many patients needing speech therapy are children, but there are many adults who can benefit from this type of care too. If you are seeking care for communication or swallowing difficulties, select a qualified and skilled therapist to ensure you get the best possible treatment and outcomes.

http://kidshealth.org/en/parents/speech-therapy.html#
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Types of Speech Therapy

Different speech therapy approaches and techniques are used for various issues

List of Types
For Late Talkers
For Apraxia
For Stuttering
For Aphasia
For Swallowing

Frequently Asked Questions

Speech therapy is not one thing. There are different types of speech therapy, each of which involves approaches and techniques that are specific to the issue that needs addressing. That could be related to speech itself—e.g., therapy for people who stutter—or it could relate to problems with memory swallowing, and more.

A speech-language pathologist (SLP), often just called a speech therapist, will perform assessments to determine which type(s) of speech therapy is right for you.

This article reviews the different types of speech therapy and the various disorders each one can be used to treat.

Types of Speech Therapy Used by Speech Therapists

A speech-language pathologist can use different types of speech therapy to help people with problems related to:

Fluency (e.g., stuttering, and cluttering)
Speech (e.g., articulation)
Language (e.g., ability; comprehension of spoken and written language)
Cognition (e.g., attention, memory, ability to solve problems)
Voice (e.g., characteristics of vocal tone)
Swallowing (e.g., stroke, congenital disorders)

In addition to different speech therapy techniques, SLPs may also provide auditory habilitation & auditory rehabilitation for people with hearing problems or disorders.

Some SLPs specialize in other services including professional voice development, accent or dialect modification, transgender voice therapy , business communication modification, and voice hygiene.

Speech Therapy for Late Talkers

A common speech therapy method is used to help children who have reached the expected age for speech development but have not started talking .

If your infant or toddler should be talking by now but isn't, they may be referred to a speech therapist. The therapist will likely try different things to encourage your child to talk, including playing with him. Sometimes, withholding a favorite toy until a child asks for it motivates small children to talk, but this depends on the circumstance.

For some children, other types of communication, such as sign language or picture cards, might be introduced. Speech therapists may also refer your child for further evaluation, such as hearing tests if necessary.

Speech Therapy for Kids With Apraxia

Certain speech therapy techniques are helpful for kids with apraxia.

Children with apraxia of speech have difficulty saying certain syllables or making certain sounds. Your child knows what they want to say, but it doesn't seem to come out right. Speech therapists are qualified to evaluate children for apraxia by using several tests, including:

Oral-motor assessment to check for muscle weakness in the jaw, lips, or tongue
Melody of speech assessment during which the therapist listens to see if they can appropriately stress certain syllables and use pitch and pauses at the appropriate place in a sentence
Speech sound assessment further determines how well the child can pronounce sounds, including vowels, consonants, and sound combinations. This includes determining how well others are able to understand the child's conversational speech

If your child is diagnosed with apraxia , they will probably need speech therapy on a one-on-one basis several times per week. This therapy will likely consist of intensively practicing their speech. The therapist will try to help your child understand auditory feedback as well as visual or tactile cues.

One way a therapist might do this is to have your child look at themselves in a mirror while speaking, or record them speaking and then playing it back. Many children enjoy this.

Since successful treatment for apraxia involves a lot of time and commitment, your therapist may give you assignments to practice with your child at home.

Speech Therapy for Stuttering

Speech therapy techniques can be applied to help treat stuttering.

Stuttering is a problem that typically develops during childhood but can develop during adulthood as well. Stuttering is usually considered a type of behavioral problem. Speech therapists will try to teach your child who stutters behavioral modification techniques that in turn may help control their stuttering.

A common method that may be used on your child is to teach them to control the rate of speech since speaking too quickly can make stuttering worse for some people. Practicing speech in a slower, more fluent manner can be helpful. It can also be helpful to monitor breathing.

Even after treatment, people who stutter may require follow-up sessions with their speech therapist to keep the problem from recurring.

Speech Therapy for Aphasia

Some speech therapy methods help people with aphasia . Speech therapy assessments can also help determine if someone has the condition.

Aphasia is a condition that causes difficulty speaking as a result of some sort of damage to the brain. The condition can also consist of difficulty listening, reading, and writing. Aphasia happens to many adults after they have experienced a stroke .

Speech therapists play a crucial role in diagnosing aphasia by evaluating an individual's ability to understand others, express themselves, and even swallow. There are many different things a speech therapist might do to help a person with aphasia, including:

Drills to improve specific language skills
Group therapy to improve conversational skills
Gestures and writing to augment their communication skills

Speech Therapy for Swallowing Difficulty

Speech therapy techniques can also be used to help people who are not able to swallow when they eat or drink.

Your child may experience difficulty swallowing for a variety of reasons. A speech therapist may help your child with swallowing difficulty by assisting them with exercises to make her mouth strong, increase tongue movement, and improve chewing.

A speech therapist may also make recommendations about the consistency of food. For infants, a speech therapist may assist in coordinating her suck-swallow-breath pattern. As previously mentioned these are only some of the things that a speech therapist might do. There are many other conditions and methods used to evaluate those in need.

There are different types of speech therapy that can be used to treat various disorders affecting speech, hearing, and swallowing. Children and adults with speech delays, apraxia, swallowing problems, and certain medical conditions may benefit from working with a speech therapist.

A speech therapist evaluates, diagnoses, and treats speech issues and communication problems, as well as swallowing disorders. They provide various services, from teaching articulation and clear speaking to helping strengthen muscles used to talk and swallow.

The four types of articulation disorders are substitution, omission, distortion, and addition. Speech-language pathologists use the acronym SODA to remember them.

Childhood Apraxia of Speech: Treatment . Asha.org.

Chang S, Synnestvedt A, Ostuni J, Ludlow C. Similarities in speech and white matter characteristics in idiopathic developmental stuttering and adult-onset stuttering . J Neurolinguistics . 2010;23(5):455-469. doi:10.1016/j.jneuroling.2008.11.004

Stuttering . Asha.org.

American Psychological Association. APA Dictionary of Psychology - Definition of Articulation Disorder .

Scope of Practice in Speech-Language Pathology . American Speech-Language-Hearing Association website.

Childhood Apraxia of Speech . American Speech-Language-Hearing Association website.

Feeding and Swallowing Disorders (Dysphagia) in Children . American Speech-Language-Hearing Association website.

By Kristin Hayes, RN Kristin Hayes, RN, is a registered nurse specializing in ear, nose, and throat disorders for both adults and children.

Recent Blogs

Speech-Language Therapy Services & Treatment

Do you or your child have communication, swallowing or voice difficulties? Our speech-language pathologists help patients of all ages develop and maintain their ability to speak more clearly, understand and express thoughts and feelings, and eat and swallow safely.

Find out more about our speech-language services:

Conditions and consultations, diagnosis and treatments.

Speech-language Therapy specialists
Speech-Language Therapy locations near you
Speech-Language Therapy providers near you

Our speech-language pathologists care for children and adults.

Conditions treated include:

Articulation problems
Augmentative and alternative communication systems
Cleft palate
Communication problems associated with autism, cerebral palsy, emotional concerns, head injury, hearing loss and pervasive developmental disorders
Delayed/disordered speech and language
Difficulty swallowing, also known as dysphagia
Executive function, such as difficulty planning and carrying out tasks
Laryngitis or hoarse voice
Laryngectomy
Oral, oropharyngeal (mouth and pharynx) or nasopharyngeal (nose or nasal cavity) cancer complications
Problem-solving and reasoning
Stroke-related deficits
Traumatic brain injury
Voice disorders

Our speech-language pathologists see patients in the outpatient setting.

Treatments provided include:

Cancer rehabilitation
Electric stimulation therapy
Fiber-optic endoscopic swallowing evaluation
Evidence-based therapy for neurological conditions
Neuromotor clinic services
Parkinson's disease therapy to improve voice communication and quality of life
Pediatric speech therapy
Swallowing difficulties and video swallowing studies
Videostroboscopy for voice assessment

Speech-Language Therapy specialists

Speech-language pathologists are licensed practitioners who are experts in assessing and treating communication disorders.

Additional care and therapies may be provided by:

Gastroenterology & Hepatology
Occupational Therapy and Physical Therapy
Otolaryngology (ENT)/Head & Neck Surgery Services
Pediatric & Adolescent Medicine

Find a speech-language therapist near you.

A referral is required, and your primary care provider can help refer you. Be sure to check your insurance plan to see if speech therapy services are covered. Call the appointment number of your preferred Speech-Language Therapy location to learn more.

What should I expect during my first appointment, and what should I bring?

During your initial visit, you will discuss your goals for therapy, and the speech-language pathologist will evaluate your speech-language concerns. After the evaluation, the pathologist will diagnose the concern and develop an individualized treatment plan with you. Your therapy team will provide education, treatment, intervention, management and counseling for you and your family.

For your first appointment, bring any imaging or medical records from non-Mayo Clinic Health System facilities. Complete a medical records release form (PDF) to authorize the transfer of health records from another healthcare facility to us. Visit our Medical Record Forms page for this form and other forms in multiple languages.

What are my payment options, and do you offer financial assistance?

Visit the billing page of your preferred location for information on insurance, billing and payments.

We serve patients in difficult financial circumstances and offer financial assistance to those who have an established need to receive medically necessary services. Learn more about financial assistance options .

Can you provide a second opinion?

Yes — simply call the appointment number at your preferred Speech-Language Therapy location . See What should I expect during my first appointment? for tips on how to prepare.

Do you have an after-hours number in case of emergency?

Always call 911 in case of emergency. For after-hours help for other issues, review our convenient care options .

Explore locations or providers near you for details on high-quality speech-language therapy:

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Speech assessment.

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Last Update: May 1, 2023 .

Definition/Introduction

Speech is a communicative skill that enables us to understand each other and to interact. It becomes a means of communication, allowing us to share ideas, beliefs, and opinions. When this process is disrupted, and the normal flow of receptive and expressive aspects of speech is compromised, a speech assessment is carried out to assess a disturbance in any part of this process. Disturbances of speech can come in the form of content formation (i.e., the patient has difficulty expressing the desired ideas in the form of spoken words) or of articulation (i.e., the patient can express their ideas in spoken form but has one or more problems physically producing the sounds necessary for intelligible speech). A speech assessment, together with formal neurological evaluation, can identify specific speech problems or patterns of speech problems, as well as propose solutions. [1]

Speech assessment is a method to evaluate and diagnose problems in adults and children of speaking, swallowing, comprehension, and writing. Such evaluation may be warranted due to neurological diseases, stroke, trauma, injury, tumors, cerebral palsy, cleft palate, orofacial musculature, hearing impairment, stammering, articulation errors, motor speech disorders, and many other conditions. [2]

Formal speech assessment is performed by a trained speech and language pathologist, and begins with a consultation in the office with the patient and potentially with family members. Reviews of prior records and treatment will be conducted, and formal characterization of receptive and expressive speech will be conducted, including articulation, fluency, content, and clarity of speech, and potentially evaluate breathing and swallowing. Objective testing such as videostroboscopy, nasometry, or rhinomanometry may be obtained, depending on the specific disorder under investigation. [3]

Issues of Concern

Speech is the verbal expression of thoughts and ideas. In many cases, speech is used to communicate via a shared language. Language is an agreed-upon rule-based code we use to communicate. Parents may present with a range of concerns regarding their children when they choose to consult a speech-language pathologist (SLP). These may include but are not limited to, the child’s patterns of speech, cognitive, and social skills in contrast to their peer group. Some parents may be concerned that their child does not match up to other children their age and appears to be lagging in milestones. These may include behavioral and hearing issues also.

Multiple tests have been devised to assess oral motor disorders. One of them is the Fletcher time-by-count test of diadochokinetic syllable rate. The diadochokinetic (DDK) rate is an assessment tool used by SLPs to measure the repetitions of sounds within a set period of time. It measures how rapid one can correctly repeat a series of rapid, alternating sounds. These are called 'tokens.' Words with one, two, or three syllables are included in tokens. For e.g. 'puh', 'puh-tuh', or 'puh-tuh-kuh'. DDK rates vary between different age groups and patients with varying neurological conditions. [4]

Normal speech depends on the functional and structural integrity of the velopharynx. This is a complex and dynamic structure that uncouples the oral and nasal cavities during sound production. Dysfunction of the velopharyngeal valve leads to hypernasality, nasal air emission, and compensatory articulation errors, all of which may impair speech intelligibility. Functional voice disorders also come under speech pathology and therapy services, in both professional and casual voice-users.

When we speak or swallow, a thin sheet of musculo-mucosal tissue called velum disunites the oropharynx and nasopharynx during speaking and swallowing. Cleft palate is a congenital deformity commonly causing velopharyngeal insufficiency (VPI), though VPI can exist independent of cleft palate also. VPI compromises speech sounds, decreases the comprehension of speech and swallowing efficacy due to improper closure of soft palate that is closed during swallowing and speaking. If the velum is not closed fully against the posterior wall of the pharynx at Passavant's ridge, this poor closure will result in nasal regurgitation and resonance disorders (hypernasality and/or hyponasality). [5]

Speech pathologists continue to develop rehabilitative strategies under swallowing management programs also. As speech and swallowing rely on many of the same sensory and motor facilities, they are necessarily related. Oral medications may also need modification in texture so the patient can swallow them safely. Likewise, daily diet modifications may be required in patients suffering from dysphagia. As patients progress through such swallowing management programs, nasogastric tube feeding, a percutaneous endoscopic gastrostomy may also be suggested via speech assessment depending on the type and severity of swallowing difficulty. Swallowing difficulties are also very common in neonatal populations, and there is a distinct sub-specialty of speech pathology dedicated to neonatal feeding. Since speech assessment is a multifactorial process, it is inclusive of the individual, their family history, health, and socio-economic status enabling insight into the circumstances relevant to individual patients' needs. For example, a child who is not responsive to the parents' or the clinician’s verbal commands may be suffering from hearing impairment, or other auditory dysfunctions. Autism Spectrum Disorder and other disorders might also be underlying issues that have not been diagnosed prior, but can be elucidated through a thorough speech assessment. Clinical conditions and communication disorders are coexisting conditions in cases of cleft palate, hearing deficit, traumatic or congenital brain injury, and anomalies of the orofacial structure and difficulty in deglutition (dysphagia). [6] [7]

Milestones are the markers that represent a standard of normal development, and there are well-defined speech, swallowing, and language skills milestones. If a child’s speech, understanding, cognition is not age-appropriate or is not like their peer group, then further investigation is warranted. There are many potential culprits, and a formal assessment of the child's hearing ability, cognition, anatomy, and home/family environment will be investigated.

Clinical Significance

Speech assessment, through its multifactorial approach, includes the child or individual’s family history, health, and socioeconomic status. It gives an insight into the circumstances they stem from, including cultural and ethnic backgrounds, which is especially relevant in multi-lingual households. [8]

A child, for example, who is not responsive to the parents or the clinician’s verbal command, may be suffering from hearing impairment or other auditory dysfunctions. Autism Spectrum Disorder and other disorders might also be underlying issues that have not been diagnosed but can be done so through thorough speech assessment. Clinical conditions and communication disorders are coexisting conditions in cases of cleft palate, hearing deficit, traumatic or congenital brain injury, and anomalies of the orofacial structure and difficulty in deglutition (dysphagia). [9]

SLPs are trained in the management of swallowing disorders as well, and there is a significant overlap with speaking difficulties. In addition to the phonatory functions of the vocal folds, they serve a protective function during deglutition. Impaired oropharyngeal phase leads to aspiration of saliva or other pathogens, including liquids/food. Poor bolus control or weak oral musculature can affect the optimum intraoral pressure that is essential for food propulsion in the esophagus. Patients with neurologic deficits may have poor oral hygiene, which acts as a medium for bacterial and fungal growth. Oral thrush is a common finding in hospitalized patients that have suffered from cerebral vascular accidents or have other neurological conditions that have impaired their speaking and swallowing ability. SLPs are consulted before a patient is started on a solid or semi-solid diet. A proper bedside swallowing test can give a general risk of aspiration in the patient. [10]

Acquired swallowing disorders are prevalent among intensive care unit (ICU) patients. Such patients face potential malnutrition, as well as problems with the administration of medications. A speech-language pathologist assesses all stages of the swallowing mechanism. In the case of poor oral hygiene, there is an increased chance of vulnerability for developing dysphagia. Early detection of oropharyngeal dysfunction will improve the prognosis and outcome of patients as they say early intervention leads to an early cure in most cases.

In the ICU, when patients are extubated, the first oral intake trial for the assessment of intact swallowing efficacy is conducted by the speech-language pathologist, after which they give the go-ahead for the provision of safe and smooth oral feeding. If any physical symptoms of deglutition are found like coughing, throat clearing during or after the oral trial, or drop in saturation, other ways of feeding are then recommended to fulfill nutritional requirements and medication intake. Rehabilitative strategies are also guided to improve the strength of oral musculature. [11]

Silent aspiration is another important feature when dysphagia is addressed. Patients suffering from dysphagia do not exhibit noticeable symptoms of swallowing difficulties. The observers that include nursing staff, attendants, and even primary consultants are not unaware of the fact that food particles and liquids have entered in patient’s lungs. Specially trained speech pathologists can suggest videofluoroscopy, also known as a modified barium swallowing test. [12]

Stroboscopy is a method of examination of a fast-moving vibrating object, such as the vocal folds. A bright flashing light lasting a fraction of a second (10 microseconds) illuminates the vocal folds. It 'freezes' the movement of the vibrating vocal folds when synchronized with a known frequency of vibration of normal vocal folds. SLPs are trained in the management of swallowing disorders as well, and there is a significant overlap with speaking difficulties. The diagnostic practice of SLPs has been revolutionized by high-speed digital imaging. This method runs at 4000 frames per second. This rate is fast enough to easily visualize the complete movement and behavior of the vocal tract. Multiple procedures like nasometry, stroboscopy, videofluoroscopy, vital stimulation therapy aid in the assessment of speech and swallowing disorders, and improving patient outcome. [13] [14]

Nasometry is a method or term used to describe noninvasive techniques for measuring the size of the velopharyngeal opening. During the articulation of speech using vowel sounds, nasometry measures the nasalance of speech. The nasality of speech is usually determined by the size of the velopharyngeal opening. [15]

Nursing, Allied Health, and Interprofessional Team Interventions

Speech-language pathologists are essential components of the interprofessional team caring for patients with voice or swallowing complaints. This team will often include one or more physicians, nurses, occupational therapists, physical therapists, mid-level providers, and many others. [16] Working in collaboration and communication with each other will help in early identification of patients in need of SLP evaluation and therapy, and help improve patient outcomes. [Level 5]

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Disclosure: Yasmin Naqvi declares no relevant financial relationships with ineligible companies.

Disclosure: Ryan Winters declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Cite this Page Naqvi Y, Winters R. Speech Assessment. [Updated 2023 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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Speech-Language Pathology in the Acute Inpatient Setting

This chapter aims to promote a deeper understanding of speech-language pathology practice in the acute-care hospital setting. Speech-language pathologists (SLPs) play a critical role in ensuring efficient, high-quality, and cost-effective patient care. Excellent clinical care for both communication and swallowing disorders in the acute-care setting requires strong and highly sophisticated clinical skills that are patient-centered and evidence-based and reflect best practice. These skills need to be informed by a balance between sophistication in understanding the clinical conditions and the medical procedures that affect the patient, and a thorough understanding of the health system continuum of care. Additionally, some key drivers for the current acute-care system have to be considered by the SLP. These include interprofessional practice and communication, cost-reduction and cost-containment measures, and a focus on quality and safety that is aligned with the goals of the particular inpatient unit and the hospital as a whole. 15.1.1 The Acute-Care Environment Acute care involves the diagnosis and treatment of active or acute health conditions, and hospitals play an important role in delivering this type of care. Acute-care hospitals are diverse in their organizational structure and mission and vary in the scope of services delivered. No matter whether they are community or tertiary care centers, acute-care hospitals are typically complex, fast-paced, and characterized by a rapid progression toward discharge. Patients are admitted for medical management, invasive procedures, and surgical interventions as a result of a serious illness or condition, or for the sequelae of an initial trauma or insult. 1 Patients’ dynamic and frequently unstable medical conditions demand frequent monitoring and assessments. The patient’s health care team works collaboratively to ensure effective medical intervention, prevention of medical complications, and timely discharge. Rehabilitation, recovery, and healing continue to occur across the continuum of care or at home after discharge from the hospital. The term acute-care hospital is broad in definition, and the acute-care hospital is characterized by a distinguishing range of characteristics, such as hospital size (including the number of inpatient beds), geographic area, specialty, population served, affiliation, and profit status (see ▶ Appendix 15.1 [p. 217]). In the United States, hospitals must adhere to performance standards established by regulatory bodies. For example, the Joint Commission (JC) is an independent, not-for-profit organization that evaluates and accredits health care organizations and programs to ensure high-quality and safe patient care. 2 All hospitals must adhere to regulations established by JC in order to receive reimbursement from Medicare, Medicaid, and private insurance. 1 , 3 Other characteristics apply to all hospitals: physicians admit patients and are ultimately responsible for directing care, while other health care professionals, such as nurses, respiratory therapists, physical therapists, and SLPs, provide critical services. 1 Some hospitals provide specialty care (e.g., ophthalmology and otolaryngology) or care of burn patients, but most are general hospitals with a full spectrum of medical departments, such as internal medicine, surgery, cardiology, neurology, etc. Other departments in a hospital provide nonclinical services (e.g., police and security) or clinical services (e.g., pharmacy). In acute settings, speech-language pathology services are typically organized as either individual autonomous departments or as part of a larger integrated service, usually rehabilitation services. However, in some highly specialized institutions, SLPs can be found in the departments of neurology, otolaryngology, or pediatrics as well as in the rehabilitation services. 15.2 The Transformation of Health Care in the United States One cannot address the topic of speech-language practice in the acute-care setting without considering the dramatic and rapidly changing health care environment. The causes are multifactorial but notably relate to insurmountable and unsustainable health care costs, serious concerns about quality of care, the burgeoning aging population, advances in technology, demands imposed by regulatory bodies, patients’ expectations and their easy access to health-related information, and health care disparity, including unequal access to care. 1 , 6 , 7 , 8 National health care reform targets cost reduction and improvement in the overall quality and safety of health care, with the expected outcome of improving the health of all Americans. 8 , 9 , 10 15.2.1 Health Care Cost and Quality Changes in the delivery of acute medical services across the United States are being implemented due to a number of governmental reforms created to guide local, state, and national efforts to improve the health care system. The national strategy focuses on improving the overall quality of care by making care more patient-centered, reliable, accessible, and safe; on improving health by supporting proven interventions and preventive is preferred AmE measures; and on reducing cost for individuals, families, employers, and the government. 8 Serious problems with quality and cost have been well documented. Although health care cost is reaching unaffordable levels, higher cost does not translate into higher quality. A variety of studies have demonstrated serious problems with the quality of health care, ranging from high rates of medical errors, preventable adverse events in health care settings, and preventable hospital admissions and re-admissions. Government programs are being implemented to stimulate innovation, to improve quality, and to decrease cost. New methods of payments, including those based on incentives and penalties or bundled payments for population management, encourage groups of providers (i.e., hospitals, physicians, and other clinicians) to coordinate care, to prevent complications, and to improve outcomes. 10 The changes in the health care system have direct implications for the SLP in an acute-care setting, trends described in an Institute of Medicine (IOM) review on health professionals’ workforce and services. 11 From acute treatment to chronic prevention and management : The goal is to manage chronic illnesses and disability through preventive measures and to avoid hospitalizations and complications that increase cost of care. From inpatient setting to home and community : Patient-centered medical homes focus on keeping the patient at home using team-based care and technology to provide care. From cost unaware to price competitive : Most people are unaware of the cost of care. Increased transparency and public reporting regarding charges for diagnostic tests and procedures are increasing consumer awareness. From professional prerogative to consumer responsive : The traditional inpatient orientation of health care gives the professional (e.g., physician, nurse) the prerogative to exercise power. Patient-centered care means the patient and family have a voice in determining goals of care. From traditional practice to evidence-based practice : Clinical decision making and interventions require strong evidence, based on applied and clinical research. From information as record to information as tool : The implementation of the electronic medical record (EMR) provides opportunities for timely and effective intervention and communication across health care systems and providers. Additionally it provides a platform for data collection and research initiatives to ensure effective and consistent management of patient populations. From patient passivity to consumer engagement and accountability : Internet access allows patients to have health-related and health care information easily available. From individual practice to team approach : Cost reduction, higher quality, prevention, and better outcomes are promoted by team-based care. 15.2.2 The Interprofessional Health Care Team Health care reform efforts to control cost have led health care providers to shift focus to a safer, better, and less costly approach to care that relies on effective collaboration, care coordination, and a team approach to care. 11 Team-based care is a strategy steadily being adopted nationwide to reduce unnecessary spending and to coordinate services so that high-quality care is delivered more economically and safely. 11 , 12 Early research evidence is showing a positive effect on care. 11 The interprofessional health care team has been defined as a group of clinicians from different disciplines who collaborate effectively with the patient and each other to address complex patient situations and problems that cannot be managed by one discipline alone. 11 Interprofessional patient care, highlighting the expertise of each team member ( ▶ Fig. 15.1 ), is especially crucial in managing patients with an acute medical condition associated with chronic illness. The SLP plays a unique and important role in identifying conditions that may be outside of the physician’s expertise (communication or swallowing), that can contribute to the complexity of care needed, and that are likely to shape outcome and discharge. Additionally, the SLP may identify new health concerns that increase a patient’s risk for infection or for complications of dysphagia, or the SLP may identify cognitive impairments that will prevent the patient from safely returning home alone. Fig. 15.1 Interprofessional team-based care. 15.3 The SLP in Acute Care: A Revised Model of Practice Historically, SLPs in acute-care hospitals have been viewed as consultants in caring for the patient and assisting patients, caregivers, and other health care providers to prepare patients for the rehabilitation process. 13 SLPs are called upon to provide differential diagnosis of communication and swallowing disturbances, to assess severity, to develop and implement short-term treatment recommendations, to monitor changes throughout the patient’s hospital course, and to communicate regularly with the patient, family, and medical and allied health care team. Throughout the patient’s hospital experience, the SLP concentrates on the patient’s discharge needs and plan for follow-up. 13 Although in today’s acute-care setting speech-language pathology remains a consultation service, the scope of practice has expanded, giving our service a broader role within the patient’s acute-care team. In essence, the traditional consultative model warrants a sweeping shift in focus that goes beyond the SLP’s acting as a consultant who provides professional advice to a physician and medical team. Current service-delivery models of health care across the continuum of care are evolving, but they consistently focus on Improving the quality of care delivered Making the care we provide safer, more effective, efficient, timely, and equitable Ensuring that care remains patient- and family-centered Making care more cost effective In the acute-care setting, a patient’s episode of care has a well-defined beginning and end, but as our model ( ▶ Fig. 15.2 ) suggests, the patient-care process cannot be viewed in a linear, step-by-step fashion. The process is dynamic, warranting continuous clinical reasoning and decision making regarding patient care, with multiple factors influencing and impacting the decisions made by the health care providers. The SLP is responsible for recognizing the multiple factors affecting his or her clinical decision making. Fig. 15.2 The SLP in acute care: a theoretical model for patient management. The new patient-centered model of acute-care SLP practice includes four essential dimensions: (1) assessment and management of swallowing, speech, language, and cognitive components; (2) identification of features of the patient’s current or predicted status or behavior that contribute to any concerns about safety, quality of care, or cost; (3) the patient and family’s values and goals for care; and (4) practice within an interprofessional team. At the center of the model are the patient and family. When care is patient- and family-centered, clinicians develop a relationship with patients and families and engage them in the decision-making process. As a result, the patient and family have the opportunity to fully participate and to convey personal values and expectations of care; personal, cultural, and psychosocial aspects are as important to consider as the goals of medical intervention and findings of the communication or swallowing assessment. With the emphasis on patient-centered care, the SLP is accountable to the patient and family, warranting patient-specific advocacy, effective communication, collaboration, and decision making. The interprofessional team approach to care, which is based on timely and effective communication among health care professionals, ensures that relevant information is considered. With a thorough understanding of the economic and quality drivers within a system of care, the long-term goals of effective, efficient, timely, high-quality care in the most appropriate setting are embedded in the SLP’s clinical recommendations and communication with the patient, family, and interprofessional team. Adding issues of safety, quality, and cost reduction to considerations about assessment, treatment, and post-discharge status and recommendations is therefore an essential part of SLP practice. SLPs need to understand hospitals’ safety and quality initiatives, unit-specific protocols, and the myriad aspects of patient-care experiences encountered in the emergency department, intensive care unit, and general care units. In order to effectively deliver care in this new model, the SLP requires considerable advanced knowledge and skill. The following represents a list of knowledge areas that are critical for the practice of acute-care speech-language pathology, and that extend beyond the basic knowledge of speech-language pathology clinical information: A thorough understanding of major body systems, interventions, and the interplay of chronic and acute conditions and their impact on cognition, speech, language, and swallowing. Knowledge and understanding of the ethical and psychosocial domains that drive patient choices and decisions and influence SLP recommendations and advocacy. Knowledge and understanding of the hospital’s medical services and health professionals comprising patient-care teams. Knowledge and understanding of care delivery systems across the health care continuum. Knowledge and understanding of health care issues, national quality and safety measures, and their impact on the institution. Knowledge of federal and state cost-containment and pay-for-performance programs affecting acute-care settings and the impact on the institution. An example of the role of the SLP in this new model relates to a hospital initiative for reducing length of stay and avoiding re-admissions as essential to reduce cost. Not only is it critical to provide a prompt response to a consult to evaluate swallowing function, but also the impressions and recommendations have to take the patient’s prognosis and disposition plan into consideration. Sometimes the SLP may feel pressured to recommend nonoral means of nutrition given patient acuity and impending discharge to the next level of care, as is the case when a medical team may be eager to place a gastrostomy tube to expedite the patient’s discharge. A discussion with the patient and family may reveal the importance of food in family gatherings and their lack of understanding regarding dysphagia and the potential for speech-language treatment to facilitate safe swallowing. When the swallow evaluation determines that the patient can swallow safely under certain conditions, a discussion with the medical team and the patient and family may result in deferring placement of the gastrostomy tube and implementing the SLP’s recommendations. In this way, the SLP contributes to (1) the patient’s quality and experience of care and (2) cost reductions by preventing unnecessary procedures. The patient in the example just cited warrants follow-up swallow treatment after discharge, and it is important to avoid a readmission with complications from dysphagia. Therefore, the hospital-based SLP must ensure verbal and written communication with the SLP caring for this patient at the next level of care after discharge from the acute setting. At times, these recommendations, which may cause slight delays in discharge or add the need for outpatient follow-up services, can be viewed by others as impediments to timely patient management. It can be useful and informative in these situations to help the other members of the team appreciate the cost/safety/quality-of-life benefits of the SLP’s recommendations The application of this new model is not limited to patients with dysphagia, as in the example of an SLP’s advocating for a supervised environment after discharge for a previously independent patient who lives alone and now presents with cognitive deficits. The SLP may need to prevent a premature discharge when the care team has not recognized the patient’s need for 24-hour supervision at home. Consideration of the delicate balance between timely and premature discharge and the factoring in of the myriad variables that can tip the outcome favorably or unfavorably must now become part of the SLP’s habitual approach. 15.4 The Consultation Process Speech, language, and swallowing consultations can be requested from multiple services, but a few, such as otolaryngology and neurology, are usually major referral sources. Other frequently referring services include pulmonary and critical care medicine, gastroenterology, general surgery, palliative care, hospitalists, and gerontology ( ▶ Table 15.1 ). Table 15.1 Examples of consulting services and the common problems treated Neurology Cerebrovascular disease, neurodegenerative disorders, brain tumors Otolaryngology Head and neck cancer, vocal fold paralysis Neurosurgery Brain tumors, cervical spine instability, aneurysms Pulmonary Aspiration, tracheostomy and ventilator requirements Gerontology Dementia, delirium Medicine Infection, delirium, deconditioning, gastroesophageal reflux, pneumonia Oncology Lung cancer, esophageal cancer, leukemia, lymphoma Thoracic surgery Lung and heart transplant, cardiac surgery, esophagectomy, tracheal resections Palliative care Dementia, metastatic cancer, amyotrophic lateral sclerosis (ALS) A written order or consult is required to evaluate and treat an inpatient in the acute-care context, and in most cases a 24-hour response time is expected. Physicians, nurse practitioners (NPs), or physician assistants (PAs) generate consultation requests, but the need for the SLP may also be identified by nurses taking care of the patient, other rehabilitation professionals, or the case manager who is dedicated to the discharge process. The acute-care SLP should have a comprehensive understanding of the practice patterns and typical clinical questions of major referral services. For example, stroke patients are referred for an assessment of aspiration risk within 24 hours of admission or before administration of oral medication, or surgically treated patients with head and neck cancer undergo swallowing evaluations on postoperative day 7. Some specialty services develop a specific order set, which may involve an SLP referral; for example, an order set may be for care of a patient with a tracheostomy and can include collaboration for tracheostomy downsize and decannulation, speaking valve readiness and training, and assessment of alternative communication for a patient unable to use a speaking valve, or the order set may require preoperative counseling and electrolarynx training for a patient scheduled to undergo a total laryngectomy. 15.4.1 Reasons for Consultation In spite of the wide variety of services requesting SLP consult, there seems to be a set number of reasons for consultation ( ▶ Table 15.2 ). The SLP is responsible for understanding the nature of the request so that the evaluation is completed in a timely, targeted, and accurate fashion directed at the question being asked. Usually, the physician’s referral contains a brief history of the patient and the reason for the referral. Sometimes consultations are predictable based on the admitting diagnosis. When the referral question is vague or ambiguous, clarification is required prior to the evaluation. Direct conversation may reveal questions that were not originally considered. This can also provide a great opportunity for educating referral sources, providing them with important concepts and guidelines for future referrals. For instance, the patient with a traumatic brain injury and tracheostomy tube may require an evaluation of swallowing, but speech production may also require evaluation because of trauma involving the velopharyngeal mechanism. Single or multiple questions may drive a consult request, including assistance with the process of differential diagnosis among disease entities or pharyngeal vs. esophageal dysphagia. Table 15.2 Reasons for consulting speech-language and swallowing services Evaluate swallowing safety Assess ability to take medications orally Coughing on liquids and solids–assess for safest diet consistency Need for a nonoral feeding method Change in vocal quality Evaluate language function Evaluate cognitive function Assist with assistive communication/nonverbal patient Appropriate level of care upon discharge Altered mental status Readiness for change in tracheostomy tube/speaking valve End-of-life decision making and helping to establish goals of care The location of the patient within the hospital may provide clues regarding medical fragility (intensive care unit or respiratory care unit), specialized services (thoracic surgery, burn unit), and the presence of major system illness necessitating admission (neurology, oncology, trauma surgery). However, highly complex patients may also be found on general medical or surgical units. Regular collaboration with frequent referral services will help the SLP preempt the consultation by obtaining a timely order and expediting evaluation and treatment. In many instances, however, the consultation request is unpredictable and the patient’s communication and swallowing needs may be the result of an unanticipated complication of the illness during that particular hospitalization. For example, a patient who underwent cardiac surgery and subsequently suffered a perioperative vocal fold paralysis may demonstrate unexpected voice and swallowing dysfunction. Because of the rapidly expanding scope of practice of SLPs, new referral and collaborative relationships are constantly being formed; thus, in many facilities, high-volume referrals may stem from a variety of services. 15.4.2 Timing and Urgency of Consult Timing of the evaluation following the request can influence the accuracy and validity of the results of the evaluation. It is important for the assessment to occur after consideration of factors that may improve validity or impact safety. For example, the somnolent patient undergoing alcohol withdrawal may not be appropriate for a cognitive evaluation until his sedating medications are decreased and his attention or alertness improves. Similarly the patient who recently underwent a bronchoscopy with anesthesia may need to wait a few hours before regaining sufficient airway protection for a swallowing evaluation. In another scenario, a procedure may be planned or under way that alters the patient’s speech, language, or swallowing status such that a preprocedure evaluation may not be helpful to further management; for example, a patient undergoing chemoradiation therapy for head and neck cancer who is experiencing mucositis and odynophagia would need to wait until the acute side effects have subsided before participating in a videofluoroscopic swallowing study (VFSS). Similarly, a patient with a brain tumor who has just undergone surgical resection with postoperative cerebral edema would most benefit from cognitive-linguistic assessment and treatment planning after the initial brain swelling has subsided. Finally, a patient in the active process of weaning from a ventilator may benefit from delaying a swallowing evaluation until respiratory function has stabilized. Alternatively, understanding the urgency of a consult request allows SLPs to predict and to manage their caseloads and to respond in a timely manner. With an urgent request, the results of a swallowing evaluation may determine the safest route of medication administration, oral or nonoral, and this could affect care and outcome. Equally urgent, a patient with a traumatic brain injury ready for discharge may require a cognitive evaluation to ensure an appropriate disposition, such as acute rehabilitation, long-term rehabilitation, or home care. The SLP has the responsibility to contribute to the discussion of candidacy for rehabilitation and the appropriate level of rehabilitation services and to advocate for the highest level of rehabilitation care by demonstrating the patient’s potential for recovery. Sometimes a consult is requested to provide information regarding a patient at the end of life or to assist in providing a means of communication for a patient to express his or her wishes in a manner that is as effective as possible. 14 , 15 , 16 This can be achieved by helping to establish an eye-gaze communication system for a patient with amyotrophic lateral sclerosis, establishing a consistent Yes/No response system for a patient with aphasia so that the team can honor the patient’s preferences, or providing voice amplification for a cancer patient too deconditioned to phonate, so that the patient may express consent or wishes. The SLP scope of practice 17 helps in determining whether the consultation request is appropriately directed to the SLP service. For example, issues related to gastroesophageal reflux or emesis may cause aspiration pneumonia, but management is best directed to gastroenterology. Similarly, management of a patient with an acute delirium induced by a toxic-metabolic disarray, polypharmacy, and/or lengthy hospital stay requires medical stabilization, which is best managed by psychiatry and/or neurology. It is important that the SLP be aware of the confines of their own scope of practice and that the SLP clearly communicate the rationale for nonintervention with the referring service as indicated. 15.5 Principles of Intervention in the Acute Inpatient Setting In the acute-care setting, one of the most essential clinical skills for effective SLP practice is expert diagnostic ability, similar to the problem-oriented approach used by physicians. 18 A strong clinical foundation and experience to competently address the swallowing and communication needs of the patient are at the core of good practice and are essential for every practitioner. In order to best answer the consultation question, provide the most accurate diagnosis, and obtain valid and reliable information, the clinician needs to understand the patient, the nature and complexity of the acute illness, and its anticipated course. A solid grasp of these factors is as important as the characteristics of the specific communication or swallowing deficit in guiding management. Furthermore, the rapidly evolving status of the patient in the context of the relatively short hospitalization stay will necessitate timely evaluation with clear impressions and plan, ongoing monitoring, and frequent changes to the plan of care. 19 15.5.1 Core Constructs That Guide the Acute-Care Intervention Understanding of Illness and the Nature of the Acute Problem The SLP assessment begins with a process of comprehensive information gathering that leads to the development of a patient history, understanding of the patient’s background, and determination of the factors that may affect the patient’s current performance. The goal is to understand the information and to integrate it into a coherent patient story that guides the assessment process and scope, and that provides the framework for further diagnostic testing. 20 In addition, the SLP should seek to understand the current status of the patient’s medical work-up, pending tests, current medications that may affect the patient’s performance, and the likely hospital timeline. In order to determine which factors in a patient’s medical history may have direct (or indirect) influence on the speech-language pathology exam, the medical SLP must have a strong foundation of knowledge about diseases, pathophysiology of illness, body systems, medication effects, 21 and medical tests and procedures. Some diseases and disorders may directly impact cognitive, communicative, or swallowing behaviors, such as brain neoplasms or laryngeal cancer, while others may have a less direct, but nonetheless critical, impact, such as diabetes or liver disease. Chronic diseases can negatively affect the patient’s overall health, strength, and endurance. Since a substantial component of management of patients in the acute-care situation is risk prediction, it is important to assemble an accurate picture of factors that might contribute to risk. A skilled clinician has knowledge of a broad base of common clinical presentations, symptoms, and patient complaints that he or she uses to detect patterns and to understand the clinical sequelae of the multitude of diseases he or she may encounter. Many medical resources are available in print and electronically to provide clinicians with understanding of diseases, current best practices, and the anticipated symptoms and treatment ( ▶ Table 15.3 ). An experienced medical SLP will use the data-gathering period to enhance the effectiveness of the search for diagnostic patterns of symptoms and patient characteristics seen in previous clinical encounters. 22 Table 15.3 Useful medical and drug resources Information on the effects of medications on swallowing, cognition, and communication Carl L, Johnson P. Drugs and Dysphagia: How Medications Can Affect Eating and Swallowing. Austin, TX: PRO-ED; 2006 Gallagher L. The impact of prescribed medication on swallowing: an overview. Perspect Swallowing Swallowing Disord (Dysphagia) 2010;19:98–102 Gallagher L, Naidoo P. Prescription drugs and their effects on swallowing. Dysphagia 2009;24:159–166 Youse, K. Medications that exacerbate or induce cognitive-communication deficits. Perspect Neurophysiol Neurogen Speech Lang Disord 2008;18:137–143 Medical Resources Atkinson M, McHanwell S. Basic Medical Science for Speech and Language Therapy Students. Hoboken, NJ: Wiley; 2002 Bhatnagar S. Neuroscience for the Study of Communication Disorders. 4th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2012 Hillis AE. The Handbook of Adult Language Disorders: Integrating Cognitive Neuropsychology, Neurology, and Rehabilitation. New York, NY: Psychology Press; 2002 Jones H, Rosenbek J, eds. Dysphagia in Rare Conditions: An Encyclopedia. San Diego, CA: Plural Publishing; 2009 Kent R. The MIT Encyclopedia of Communication Disorders. Cambridge, MA: The MIT Press; 2004 Longo D, Fauci A, Kasper D, Hauser S, Jameson JL, Loscalzo J. Harrison’s Principles of Internal Medicine. 18th ed. New York, NY: McGraw-Hill; 2011 Netter F. Atlas of Human Anatomy. 5th ed. Philadelphia, PA: W. B. Saunders; 2010 Porter R. The Merck Manual of Diagnosis and Therapy. 19th ed. Whitehouse Station, NJ: Merck; 2011 Remmel K, Bunyan R, Brumback R, Olson W. Handbook of Symptom Oriented Neurology. 3 rd ed. Philadelphia, PA: Mosby; 2002 Webb W, Adler R, Love R. Neurology for the Speech-Language Pathologist. Philadelphia, PA: Mosby/Elsevier; 2007 Yorkston K, Miller R, Strand E, Britton D. Management of Speech and Swallowing Disorders in Degenerative Diseases. 3rd e). Austin, TX: PRO-ED;2012 Electronic Resources eMedicinehealth. http://www.emedicinehealth.com Medline Plus. http://www.nlm.nih.gov/medlineplus/medlineplus.html Medscape Reference. www.emedicine.medscape.com UptoDate, Inc. online. www.uptodate.com WebMD. http://www.webmd.com Multiple sources of information can be tapped for the relevant data, including Medical chart review of current hospitalization History gathering of past illnesses, surgeries, other hospitalizations Discussions with other team members: nurse, physician, allied health professionals, case manager Patient/family interview The clinician needs to make note of, and to understand, the following patient characteristics (see ▶ Appendix 15.2 [p. 224]): Current hospitalization course: It is important to review the reason for the admission, the circumstances of the onset of the acute event, timing of the presenting symptoms, and the nature and course of the patient’s current illness. This review includes results of diagnostic tests, such as imaging (CT scans, MRI, chest radiographs), cardiac and pulmonary function testing (e.g., echocardiogram and bronchoscopy), and laboratory data that may provide information regarding infection, dehydration, and malnutrition. The SLP should assemble information regarding the patient’s management to this point, such as surgical procedures, need for invasive ventilation, drug therapy, and the patient’s overall response to the treatments. To make sense of the information, it may be helpful to organize the aspects of the hospital course into body systems, such as pulmonary, cardiac, neurologic, and gastroenterologic, paying more detailed attention to the systems that would have a direct effect on the domains relevant to the SLP. Nutrition and cognitive function over the course of the hospitalization deserve close attention when gathering information. The route of nutrition delivery (e.g., orogastric tube, nasogastric tube, intravenous) during the hospitalization should be defined, and the SLP should assess whether consistent nutrition has been affected by self-removal of nasogastric feeding tubes or gastroparesis causing regurgitation or emesis. With respect to cognitive status, it is important to learn how the patient has reacted to hospitalization; for example, confusion, delirium, somnolence, and agitation are behaviors that, if persistent, affect the management plan. Previous medical and surgical history: Previous hospitalizations for the same illness or other illnesses and previous procedures and testing provide important clues regarding chronicity of the condition, complexity of the disease process, and whether previous interventions have been successful. Furthermore, a history of dysfunction in one system may directly contribute to current functioning of another system; examples include dementia, psychiatric illness, progressive neurologic disease, or radiation therapy to the head and neck─all of which can affect speech and swallowing. Psychosocial factors: These important factors include family structure and dynamics, level of independence at baseline, educational background, employment situation, cultural values, and languages spoken, all of which affect the care the patient may require upon discharge. Current status: Understanding the patient’s medical status at the time of the evaluation, as well as deriving an understanding of the likely course of the patient’s condition(s) from this point onward, is crucial to the diagnostic process. The medical chart details the patient’s hemodynamic status, cardiac function, pulmonary function (including oxygen requirements, pulmonary treatments, and the patient’s response), and cognitive and behavioral status, such as orientation, awareness of condition, level of agitation or somnolence, and ability to communicate, as well as the need for nonoral nutrition, invasive ventilation, medications, procedures, etc. The development of a plausible therapeutic plan can be accomplished by determining overall patient behavior. The need for restraints or inability to cooperate with assessment likely signifies a patient’s limited ability to participate in feeding/swallowing activities. The patient’s level of pain (local or global) may hinder accurate assessment as well. Is there any planned procedure that may interfere with the speech-language evaluation or require rescheduling of speech-language intervention? Will a recently performed medical or surgical procedure affect the SLP’s findings, such as bronchoscopy? Does the patient require significant sedating medications to manage his/her behavior and, if so, do they interfere with the patient’s ability to participate in an evaluation? Safety precautions: Prior to initiating the evaluation, safety precautions should be ensured. These may range from standard precautions, such as completion of hand hygiene before and after entering the patient’s room, to fully understanding medical restrictions, hemodynamic status, and any upcoming or just completed procedures that may render the patient unsafe or unable to take anything by mouth for a specified period of time (e.g., transesophageal echocardiogram (TEE), upper GI series (UGI), bronchoscopy, etc.). Similarly, because patient status can fluctuate, it is imperative that, before all follow-up visits, the SLP confirm with the nurse and check daily orders regarding patient’s recent events, current status, and changes in diet orders. Safety factors to consider include Bed restrictions–Is it safe for the patient to be out of bed? Does the patient require a bed rest order? Head of bed elevation precautions/restrictions–Is it safe for the patient’s head to be fully elevated for the SLP evaluation and for meals? Does the patient need to lie flat? Does the patient require a brace in order to sit up? Feeding/oral intake status–Does the patient currently have an NPO order (nothing by mouth) for any particular medical procedure that precludes a swallow evaluation and diet initiation at this time? Are there any fluid or free water restrictions that would affect the amount of fluid/water that can be provided? Does the patient have any food allergies that should be noted to guide the foods presented? Restraint status–Does the patient require restraints and can they be removed during the speech-language session? Hemodynamic status/stability–Is the patient’s medical and respiratory status stable or is the patient currently too fragile for oral intake? Is the patient stable enough to be taken off the floor for a VFSS and is nurse accompaniment required for monitoring? Infection control/contact precautions–What infection control precautions must be followed when entering the patient’s room, such as gloves, gowns, masks, and hand washing? Medications: Medications can directly affect a patient’s state of arousal, speech, or swallowing, can exacerbate cognitive-communication deficits, and/or can impact restoration of health. 21 Youse 21 states, “It is recommended that speech-language pathologists thoroughly investigate any medication a patient may be prescribed to determine if and how it may affect cognitive-communicative ability.” It is useful to have resources and references that describe the effects of prescribed medications ( ▶ Table 15.3 ). Code status and patient wishes: These factors include the patient’s preferences regarding life-sustaining measures, health care proxy, and orders regarding the patient’s or family’s desires about intubation, resuscitation, and enteral nutrition. Alignment of SLP goals with the patient’s code status and defined life-sustaining treatment wishes is essential to making recommendations and determining how best to provide care. For example, a patient with clearly defined preferences for no alternative hydration or nutrition may best benefit from intervention that supports patient decisions, promotes quality of life, and educates the patient and family about ways to minimize distress and discomfort, rather than intervention that limits certain food items or alters diet consistencies. Discharge planning/status: It is important for the SLP to be aware of the overall disposition and prognosis and to have a general sense of the immediacy of the discharge and the level of care being considered. If the patient will be going home, it is important to ascertain the level of family support and how it may interact with the recommendations of the SLP, as well as insurance issues that may curtail outpatient care. These factors are critical in the attainment of discharge goals and for a successful outcome for the patient. The following case example demonstrates how understanding the nature of the illness and the patient’s current medical status can affect the SLP. Mr. B, a 90-year-old male, was admitted from his nursing facility with cough and hypoxia as a result of recurrent aspiration pneumonia. He was reportedly “choking on his meals” at the nursing facility. He has a history of chronic obstructive pulmonary disease and severe esophageal dysmotility with reflux due to chronic opioid usage and a noted hiatal hernia. He had been hospitalized nine times in the previous 2 years for hypoxia, cough, and pneumonia. The speech-language pathology service was consulted during two of his last admissions secondary to chest X-ray findings indicative of pneumonia and reports of choking. A videofluoroscopic swallow study (VFSS) was completed 1 year prior to the current admission. The VFSS documented a mild oropharyngeal dysphagia primarily characterized by delayed airway closure, resulting in trace laryngeal penetration and aspiration with thin liquids prior to airway closure. The patient sensed the aspiration on most occasions and coughed the material out of his airway. The remainder of his oropharyngeal swallow function was adequate. The strategy of small, single sips of water with frequent breaks in between was successful in eliminating the airway penetration. The findings of the swallowing evaluation with minimal airway invasion and a robust airway protection response did not align with the degree of pulmonary compromise necessitating the frequent hospital admissions for pneumonia. Alternative explanations were necessary. Extended conversations among the health care team, the patient, and the patient’s daughter revealed a history of regurgitation and heartburn that possibly explained the symptoms and the etiology of the pneumonia but that would require further investigation. The patient and his daughter declined a gastroenterology consultation to manage the esophageal dysphagia and wished to continue with an oral diet given the patient’s desire to eat. Thus, it was determined that likely further aspiration events could not be prevented despite lifestyle changes to minimize reflux. The decision was made to initiate a “do not hospitalize” order and the patient was discharged back to his nursing facility with routine antireflux precautions. Patient/Family Interview By completing a thorough and sensitive patient/family interview, with particular attention to presenting symptoms and their duration and severity, the SLP can begin to determine if the nature of the problem is acute or chronic ( ▶ Table 15.4 ). Table 15.4 The medical interview Components of the Interview Rationale 1. Greetings and ensuring patient comfort Clear introductions help to set the stage for an effective interaction. Sit down to speak with the patient. 2. “Calibrating” the interview Valuable information about the patient’s communication style and behavior is obtained, as well as a tentative list of problems. 3. Questioning, listening, and observing “What kind of problems have you been experiencing?” and other open-ended questions encourage the patient to report problems before the clinician initiates a more detailed inquiry. 4. Facilitation techniques Encourage and guide the patient’s spontaneous report while exerting as little clinician control as possible. 5. Patient’s chief complaint “Which of your problems concerns or bothers you the most?” will allow the clinician to understand the importance of the problem to the patient. 6. History of present illness (HPI) or story of illness Following leads obtained during the discussion, the clinician collects pertinent information about the relevant diagnosis, looking for symptom complexes or diagnostic patterns that assist in clarifying the diagnostic hypotheses. 7. Transitional statements Before proceeding with each new section, make a clear transitional statement. 8. Past medical history, social history, symptom checklist Completes the patient profile. 9. Closing the interview Ask the patient if there is anything else he or she would like to share regarding his/her concerns. Based on Lichstein’s elements of a medical interview. 23 Not only is the interview a powerful diagnostic tool that guides the clinician’s next steps in the process, but also it provides the SLP with an opportunity to establish rapport and develop trust, which must occur quickly in the acute environment. 23 Furthermore, Lichstein 23 states, “The interview is a collaborative effort between physician and patient.” An open question format will yield the most information. The SLP should be sensitive to the fact that he or she is one of several health care providers requesting information that day, often with similar questions. Throughout the interview, the SLP can keenly observe the patient for accuracy of responses, communication effectiveness, overall mental status, and level of concern and awareness regarding the presenting deficit. These observations will also help to target the assessment, which is essential, because patients with acute illnesses likely cannot pay attention for a long period of time. Hypothesis Testing and Differential Diagnosis Based on information gathering and history taking, the SLP understands the reason for the hospital admission and the nature of the clinical question, and begins to formulate a hypothesis about the potential or anticipated cognitive-communicative and/or swallowing disorder. The formulation of a logical and thoughtful hypothesis directs further assessment and data collection. Johnson and George 24 state, “The hypothesis should be based on the presenting information about the patient, the patient’s condition and available history, as well as the SLP’s extensive knowledge of the discipline.” They caution that “without a reasonable hypothesis to be tested in diagnostic activity, the clinician is likely to expend time in unnecessary testing” (p. 341). Forming a hypothesis or differential diagnosis narrows the possibilities and leads to a focused and organized assessment. Once a hypothesis is formulated, the assessment is then designed to rule in or rule out the potential hypothesis, and the appropriate selection of test materials enables the clinician to identify the presenting problem (or problems), helps reach the most likely explanation for why the patient is experiencing a particular deficit, and assists in treatment planning and deciding on a likely prognosis. 25 , 26 Further, the speech-language differential diagnosis can contribute to and inform the medical differential diagnosis. 6 Some examples of the potential differential diagnoses considered by SLPs in acute-care settings may include Oropharyngeal vs. esophageal dysphagia Acute vs. chronic vs. progressive disorder Cognitive vs. linguistic deficit Language vs. motor speech disorder Behavior/motivation problem vs. cognitive impairment Upper motor neuron vs. lower motor neuron disorders Apraxia of speech vs. dysarthria Functional (psychogenic) vs. neurogenic communication impairment 15.5.2 Case Study 1 The SLP received a consult request for assessment of swallowing in an 82-year-old retired priest with confirmed dementia, who resided in an assisted living facility (ALF) for clergy. The patient was admitted following the fourth fall of an unknown nature in the past several weeks. The medical record was limited, because the majority of his care had been at an outside facility. Head imaging revealed no new brain injury; however, the patient had multiple chronic lacunar infarcts, including in the bilateral basal ganglia and cerebellum. The consult request for speech-language pathology services stated, “Patient with dementia, coughing when drinking and can’t chew solids, please advise appropriate diet.” Following the chart review and an interview with the caregiver from the ALF, the SLP met the patient. During the patient interview, she noted slurred and imprecise speech consistent with an ataxic dysarthria. In the interview, the patient demonstrated good awareness, memory, and orientation, and he was able to provide a detailed account of his most recent fall that was consistent with the medical record. He also expressed concern that his recent falls occurred during the night when he woke up to go to the bathroom, and he stated that his difficulties began several months earlier when he suffered a stroke. The SLP, hypothesizing that the primary etiology was residual stroke impairments rather than dementia, completed a focused assessment to target oral-motor, speech, and swallowing function and that identified strategies and compensatory maneuvers to improve speech intelligibility and minimize aspiration. In conversation with the physical therapist, it was noted that the patient had poor balance and disrupted gait, which are also consistent with cerebellar dysfunction. After the above information was presented to the medical team, it was determined that the most likely cause for the frequent falls and speech and swallowing dysfunction was neurogenic. A neurology consult was generated to assist with stroke management and prevention, a geri-psychiatric consult was requested to assist with a more accurate determination of dementia, and the patient was referred to an inpatient rehab setting for speech, physical, and occupational therapy. Patient Complexity and Risk Assumption As a result of medical and technological advances, patients in acute-care settings are increasingly complex in their medical presentation. The care of patients is becoming more time and resource demanding, necessitating an increasing ability to integrate a broader amount of information into the care process. However, in its broadest sense, it is not just the number of medical conditions that increase the complexity of caring for a patient, but the interplay of multiple, coexisting conditions. 27 A patient with numerous, chronic, frequently encountered medical conditions (such as coronary artery disease, diabetes, and chronic obstructive pulmonary disease), deficient baseline cognitive status, limited financial means, and advanced age will require creative and thoughtful planning by the entire multidisciplinary team to achieve the best health outcomes. Likewise, the speech-language intervention must also consider a multitude of domains (medical, psychosocial, cognitive, ethical) and incorporate this knowledge into determining patient care needs. Specific considerations for the SLP in caring for a complex patient are listed in ▶ Table 15.5 . 27 , 28 Table 15.5 Assessment decisions in acute care versus rehabilitation Acute Care Rehabilitation What is the problem? What are the impairments and functional limitations? What is the cause? What is the cause? What are the severity and prognosis? What are the severity and anticipated course of recovery? Is patient’s behavior/communication/swallowing consistent with the medical condition? Is patient’s behavior/communication/ swallowing consistent with the etiology? Is there any immediate medical/surgical intervention available to help the patient? What treatment will be beneficial for these impairments? What speech-language-swallowing intervention is needed? Is treatment helping? What additional follow-up will be needed? If not, what changes to treatment are indicated? How can the results of this assessment contribute to overall patient care and safety? How can the results of this assessment help plan for best functioning after discharge? Adapted from Johnson et al, 29 p. 339. The concept of medical frailty as it relates to assumption of risk in decision making also deserves close consideration in the acute-care environment. Bortz 30 defines frailty as “a state of muscular weakness and other secondary widely distributed losses in function and structure that are usually initiated by decreased levels of physical activity” and notes that “acute events conspire in major ways to provoke frailty” (p. 284). Risk factors for provoking frailty include toxins, infections, injuries, and malignancy, all exacerbated by nutritional problems. Frailty, generally thought of in terms of the elderly, is considered a biologic syndrome characterized by diminished reserve and decreased resistance to stressors resulting from cumulative declines across multiple physiologic systems. 31 Specifically, diminished physical activity due to muscle weakness results in slowed performance, fatigue, poor endurance, and unintentional weight loss. 30 Frailty can occur in younger patients with severe deconditioning after critical illness. Frailty leads to reduced functional reserve and increased vulnerability. 32 , 33 The medical SLP must consider the overall state of the patient and what complications might ensue should the patient aspirate, contract an infection, or receive insufficient nutrition. Frail patients do not have the reserve or capacity to fight off infection, are rarely ambulating to maintain endurance, may have a weak, ineffective cough with reduced airway protection should aspiration occur, and may be too easily fatigued to consume sufficient nutrients. Consideration of frailty, along with specific swallowing function impairments, will lead to more focused and appropriate management, with an emphasis on overall patient health status and safety. 32 , 34 15.6 Targeted and Appropriate Assessments The SLP in the acute-care setting tailors the assessment to identify the presence and severity of deficits systematically, to interpret their clinical significance, and to confirm or rule out likely diagnoses. ▶ Appendix 15.3 describes the main components of an SLP evaluation; however, these components will be tailored according to each specific patient’s needs. The assessment must answer the question asked by the consulting service relative to the presenting complaint. Because of time constraints and patient characteristics, the assessment may be limited to the issues that have the greatest impact on the patient’s medical stability and on the discharge decision making process for the patient, family, or team (Table 15–6). Table 15.6 Considerations in caring for the complex patient Multiple chronic conditions = increased risk of pneumonia increased likelihood of multiple medications increased likelihood of reduced ambulation Poor mental status = inability to maintain arousal during a meal inability to recall safe swallowing strategies inability to attend to treatment activity Limited financial means= limited rehabilitation options reduced finances for medications and treatment Limited family/social supports= unsafe living environment lack of assistance at home for daily living activities inability to drive to outpatient treatment, medical appointments, and for personal needs Advanced age= increased fragility increased comorbidities The clinician must be a keen and sensitive observer, meticulously recording all behaviors, gross and subtle, as the patient may tolerate only a brief encounter. The process of data collection and symptom monitoring must be efficient to generate an appropriate diagnosis. Repeated short visits may be more appropriate than a single long evaluation session. Formal testing can provide the clinician, particularly one with less experience, with a hierarchical framework to evaluate a particular function. With experience, astute observational skills, and intuition, clinicians can modify formal testing to facilitate extrapolation of information. During the initial assessment, the clinician should be prepared for discovering unanticipated speech, language, and/or swallowing findings, which may necessitate a rapid adjustment in the exam to match the patient’s needs, to best elicit and define abnormal behaviors, and to add to an alternative hypothesis. Furthermore, given the rapidly changing acute-care patient, the patient may be too lethargic, too medicated, or too ill to complete the assessment in one session or to complete all facets of the exam. Alternatively, the SLP may vie for time with competing tests, procedures, and other medical consultants. 15.6.1 Case Study 2 Ms. T, a 62-year-old female, was admitted to the general medicine service with increasing weight loss and dehydration. Her work-up by the medical team revealed progressive speech changes, upper extremity weakness, including mild loss of fine motor dexterity in her hands, and shortness of breath without a known cause. The oral-motor speech evaluation yielded diagnostic clues, including fasciculations of the chin and tongue, hyperreflexia (jaw jerk, suck and snout reflex), and mixed flaccid-spastic dysarthria. The SLP strongly suspected that the constellation of these upper and lower motor neuron findings pointed to a motor neuron disorder and warranted neurology consultation. To accommodate the patient’s fatigue and difficulty chewing, the patient’s diet was modified to a soft diet and a nutrition consultation was advised to assist with strategies to maximize nutrition and hydration. Although the diagnosis of ALS was strongly suspected, the medical team determined that until the diagnosis was confirmed, long-term-care issues, such as placement of a feeding tube, determination of patient wishes regarding life- sustaining measures, and alternative communication methods, should be deferred to care in the outpatient setting. 15.7 Cognitive-Communicative Assessment in Acute Care Although the evaluation of a patient’s swallowing ability and the need to determine a safe mode of nutrition may typically constitute the primary reason for referral, the SLP should not fail to address all parameters that fall within the SLP domain, including language, cognition, communication, and speech. The importance of addressing the patient’s communication abilities should not be overlooked. The SLP advocates for communication needs, provides patients and families with education and support, and provides valuable information about the patient’s cognitive-communicative status to the health care team. 35 Often, changes in speech, language, or cognition may be the initial presenting symptoms of an underlying neurologic condition and the SLP assessment may be critical to guiding the diagnostic process. 26 Both standardized and nonstandardized assessments may be utilized depending on the purpose of the assessment and the patient’s ability to participate. In general, formal treatment planning does not occur during the acute hospital stay, so the diagnostic process needs to be focused and individualized to the patient’s needs. 36 Key questions may include the following: Does the patient have a problem? If there is a cognitive-communicative disorder, what are its characteristics? What are the implications of the test results beyond the test session? 37 Furthermore, the realities of acute care today demand cognitive-linguistic testing that is not only well designed, but sensitive, standardized, and quantifiable, yet brief. 13 , 38 Several excellent evidence-based reviews and recommendations include ASHA’s Compendium of EBP Guidelines and Systematic Reviews http://www.asha.org/members/ebp/compendium/ ANCDS (Academy of Neurologic Communication Disorders and Sciences) Practice Guidelines and Practice Resources http://www.ancds.org/ COMBI (The Center for Outcome Measurement in Brain Injury) http://www.tbims.org/combi/ Practice Guidelines for Standardized Assessment for Persons with TBI. ANCDS Bulletin Board/Vol. 13, No. 2 Several tools that are both well designed and tested, as well as useful for neurocognitive assessment and/or monitoring in the acute-care setting, can be found in ▶ Table 15.7 . This is not an exhaustive listing, however. The SLP also should be mindful that a brief cognitive screening may not be sensitive enough to detect higher-level executive function impairments. It may be useful to pair a brief cognitive screening with a structured interview and informal executive function tasks. And, as always, the SLP must synthesize the patient’s information, including age, community needs, baseline functioning, family support, neuroimaging findings, loss of consciousness, etc., to better determine risk factors and to formulate a focused plan. Referral for a follow-up outpatient neuropsychological and/or SLP cognitive-communicative assessment after discharge may be useful too, for patients with impairments. Table 15.7 Neurocognitive tests for assessment and monitoring in acute care Behavioral scales Glasgow Coma Scale Ranchos Los Amigos Scale Cognitive measurement tools Mini-Mental State Examination (MMSE) Galveston Orientation and Attention Test (GOAT) Cognitive-Linguistic Quick Test (CLQT) Scales for Cognitive Communication Ability for Neurorehabilitation (SCCAN) Montreal Cognitive Assessment (MOCA) Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) JFK Coma Recovery Scale Cognistat Neurobehavioral Cognitive Screening Evaluation (NCSE) Agitated Behavior Scale (ABS) Language measurements Western Aphasia Battery (WAB) Boston Diagnostic Aphasia Evaluation — short form (BDAE) Boston Naming Test (BNT) Functional communication measures ASHA-Functional Assessment of Communication Skills in Adults (ASHA-FACS) 15.8 Swallowing Assessment in Acute Care The purpose of the clinical swallowing examination in acute care is to determine the patient’s safety and efficiency for oral intake. The concepts of safety and efficiency take on a unique significance in the context of acute hospitalization. Whereas in the outpatient setting recurrent or persistent aspiration may be tolerated by the patient to the extent that oral intake may be feasible, in the acute-care context, hospital-acquired pneumonia, such as aspiration pneumonia, may be extremely detrimental to the overall outcome and therefore its prevention is crucial. At the same time, nonoral nutrition carries its own risks of complications, such as sinusitis from the long-term presence of a nasogastric feeding tube, dislodgement of the feeding tube, intolerance to tube-feed formula, and increased oral colonization in a patient who is NPO. Thus, the SLP performs a delicate balancing act between maintaining NPO status and initiation of an oral diet, ensuring team collaboration when making nutritional recommendations for a patient in the acute-care situation. Depending on the diagnosis and because of the effect that aspiration can have on the patient’s hospitalization and overall outcome, it is the clinician’s responsibility to “disprove” aspiration, as well as to prove safe swallowing. Furthermore, the acute-care SLP must always be vigilant in considering the reliability of the data collected in any one diagnostic session to predict overall function. If it is only possible to evaluate the patient with a few bites or sips before needing to stop because of patient response, data collection may be inadequate and further evaluation at a later date may be required. Representative sampling, a construct open to interpretation, is needed to predict behavior under regular circumstances, when fatigue, distraction, pain, and attention deficits may interfere with swallowing safety and efficiency. 15.9 The Role of Instrumental Evaluation in Acute Care It is well known that the clinical bedside evaluation has significant limitations with respect to validity and reliability, . 39 , 40 Since understanding the physiology of the swallow in addition to other patient variables is critical for making recommendations for safe oral nutrition, many patients in the acute-care situation may be candidates for an instrumental evaluation. Choosing the type of instrumental exam and the timing of the exam may depend directly on the question at hand, taking into consideration the type of instrumental test available, patient factors like hemodynamic and medical stability, the patient’s ability to follow directions and to complete strategies, the patient’s overall level of debilitation, and scheduling constraints in the facility. Some acute-care hospital environments only have access to VFSS. Where laryngoscopic evaluation of swallowing is possible, selection of fiberoptic endoscopic evaluation of swallowing (FEES) over VFSS relates to the question being asked and the patient’s status. A patient in intensive care may not be sufficiently stable to travel to the radiology suite for VFSS, or positioning or body habitus (patient’s physical condition) may preclude a radiologic assessment. However, if an esophageal disorder is suspected, the patient may not be appropriate for FEES. Direct visualization of laryngeal function is appropriate if the question relates to secretion management or vocal fold function or another structural abnormality. In experienced hands, FEES can provide essential information about the physiology of the swallow and can demonstrate the impact of therapeutic strategies. Sometimes more than one procedure is required. A FEES study may be performed as a preliminary investigation in the knowledge that VFSS may be necessary when the patient can safely to travel the radiology suite. The expertise of the clinician in performing the instrumental examination will also contribute to the data that are derived. Descriptions of VFSS and FEES can be found in Chapter 10 and Chapter 11 of this text, respectively. Precautions should be taken in performing instrumental examinations in the acute-care setting, and, in light of a patient’s fluctuating medical status, it is important to update status immediately prior to conducting the examination. Patients may be restricted with respect to positioning. The SLP should inquire about the patient’s need for hemodynamic monitoring with cardiac telemetry or for oxygen saturation. In such situations, a nurse or respiratory therapist may need to accompany the patient to the radiology suite for the examination. Specific precautions to be communicated to the radiology staff regarding the patient include positioning constraints and infection precautions (such as methicillin-resistant Staphylococcus aureus [MRSA]) so as to protect both the staff and the patient. Endotracheal suctioning equipment should be set up in preparation for the patient who has a tracheostomy tube or who has difficulty managing secretions. Following the swallow study, the patient should be carefully positioned and should be monitored closely while awaiting transport back to the hospital unit to ensure safe transfer. With respect to FEES, similar precautions are necessary. Clinicians should check with the referring service regarding the patient’s coagulation status, because introduction of the endoscope can cause bleeding. Patients with facial fractures, hemodynamic instability likely to promote vasovagal events, or recent administration of tissue plasminogen activator (tPA) or those on noninvasive ventilation may not be candidates for FEES exams. 15.9.1 Synthesis of Test Findings with Patient Factors to Make an Informed Clinical Judgment The SLP synthesizes the specific findings on the exam and the nature of the disorder with the patient’s medical diagnosis, medical care plan, and anticipated outcome in order to make appropriate clinical decisions and to recommend treatment. 41 Description of etiology, differential diagnosis, a focused treatment plan with a clear rationale, and a prognostic statement are the hallmarks of powerful clinical communications. Murray 42 states, “The clinician should describe in exact terms the potential for poor outcome should treatment not be provided. Recommendations should directly respond to the consulting physician’s interest in requesting the consult.” Both immediate and long-term needs of the patient should be addressed. Case Study 3 Ms. G, an 81-year-old female, was relatively healthy until 6 months earlier, when she began to decline functionally, to experience changes in her swallowing ability, and to lose weight. She was admitted to the hospital with pneumonia, rapidly developed pulmonary and cardiac complications, and suffered a small left hemispheric stroke. She received tPA in the hospital and the majority of her acute stroke symptoms resolved. During the SLP interview, the patient confirmed gradually worsening swallow function over the prior 6 months, including a sensation of hard food items and pills sticking in her throat, intermittent immediate regurgitation, coughing when drinking large sips of liquid, and increased time needed to eat. The dysphagia assessment, including a VFSS, showed a moderate-size Zenker’s diverticulum in addition to base of tongue retraction and bilateral pharyngeal weakness. These impairments resulted in reduced bolus drive, causing a significant pharyngeal residue that necessitated multiple swallows per bolus. The residue resulted in mild persistent aspiration on liquids after the swallow and elicited a weak, ineffective cough. Integrating the findings of the clinical and instrumental examinations gave the impression of acute dysphagia imposed on chronic dysphagia. The patient’s swallowing dysfunction predated and likely precipitated the admitting aspiration pneumonia and was exacerbated by the acute cerebrovascular event. The underlying problem rendered the patient fragile and easily fatigued. Although compensatory therapeutic swallowing strategies, including head rotation, multiple swallows, and liquid rinse, all assisted in clearing the pharyngeal residue, the energy expenditure required to complete these strategies for oral nutrition at a meal was determined to be too significant. Neither the gastroenterologist nor the SLP judge the diverticulum to warrant repair, given the patient’s medical fragility. The SLP recommended nonoral alternate hydration and nutrition as a bridge during the rehabilitation phase, as well as small amounts of oral intake for comfort using the prescribed compensatory strategies. The SLP predicted that once the patient’s medical course stabilized, inpatient rehabilitation would focus on maximizing her ambulation, overall endurance, nutritional status, and swallowing function, allowing her to resume oral nutrition and to return home with her family. Communication of Findings to Health Care Team, Patient, and Family Communicating the findings of the evaluation to the health care team in an effective and efficient manner is challenging, yet is critically important in the acute-care setting. Updating status changes and recommendations throughout the hospitalization is further challenged by the abundance of chart notes, reports, and other consultations that fill the patient’s medical record. Murray 40 notes that “the value of even the most effective and artfully applied assessment is reduced without skillful, concise, and accurate communication of our activities.” Many providers in rotating teams interact daily with patients in large, fast-paced tertiary care or academic medical centers. Medical residents work in a team, so that each day a different resident may be the primary contact person. Nurses change their shifts and are not necessarily assigned to the same patients on consecutive days. Hospitalists, nurse practitioners, and physician assistants may also work varied and intermittent shifts, with frequent hand-offs to one another each day. Family members may visit after the workday has ended or on weekends. Furthermore, patient care rounds may or may not take place daily, and the SLP may or may not be available to attend. Given these challenges, the following are several key guidelines: Communication needs to take place on a continuous basis. Information should be presented in varied formats, e.g., the EMR, paging, phone calls, oral report to team members, team meetings. Findings, recommendations, and changes to the patient’s status along the way need to be made in a timely manner, and need to be be concise, but must also convey the SLP’s thought process and opinion. Communication should involve all members of the health care team as needed (nurse, PT, case manager, dietician, etc.), as well as the patient and the primary caregivers. Information should be presented in a manner that is sensitive to the patient’s or family’s emotional state and considers the sense of crisis that they may be experiencing. Experts in counseling and end-of-life issues, such as social workers and palliative care consultants, should be utilized to assist with difficult discussions. Written Documentation Because of the essential nature of the written report, and its importance in communicating the clinical work performed, documentation needs to be thorough and effective, yet concise and succinct. The quality of the written report will help to establish the quality of the SLP service and can make a lasting impression on the reader. 40 Documentation primarily serves to record the clinical history, problems, and course of care; to communicate with other practitioners; to document services for quality assurance and reimbursement purposes; and to act as legal evidence in a court of law. 43 The documented information becomes part of the permanent and legal medical record and supports patient billing. Documentation is completed and placed in the medical record immediately after the patient encounter. Written documentation in the acute setting generally includes: Diagnostic reports Progress notes Discharge summaries Letters/email to the patient and/or other providers The format and process of documentation vary greatly from facility to facility, although regulatory bodies, such as the Joint Commission, dictate minimal standards. Each institution will have its own documentation conventions. These can include checklists and narrative, and often some combination of the two. Regardless of the style, the consult report and subsequent progress notes are composed of several key, standard sections ( ▶ Table 15.8 ). Table 15.8 Standard sections of written documentation Evaluation Report Progress Note Section Description/Contents Introductory Statement History of Present Illness Previous Medical and Surgical History Subjective Patient history, complaints, current status/presentation, reason for consultation or visit Examination Objective Objective clinical data: exam parameters, tests given, measurements, diagnostic observations without interpretation Impressions Assessment Diagnosis/current state of the swallowing, communication, or cognitive deficit; integration of all the objective data with SLP interpretation; changes from previous sessions; proposed interventions and patient response; severity and prognosis Recommendations/Plan Plan Recommendations to the consulting MD regarding patient management; direct response to the consult question; plans/rationale for ongoing intervention; additional referrals recommended; discharge plan/status and need for SLP services Patient/Family Education Patient/family education Describes information provided; reviews findings and recommendations; indicates patient’s/family’s level of understanding, barriers to education, and ways to overcome them SLP = speech-language pathologist The development and implementation of the electronic medical record (EMR) have surged over the last several years with health care reform changes and in an effort to promote a safer and more cost-effective health care system, although many hospitals are still struggling to adapt to the changes. 44 , 45 Each documentation format has benefits and limitations, but the principles of documentation will determine the most appropriate format for a particular institution ( ▶ Table 15.9 ). Table 15.9 Guiding principles for documentation Reflects careful observation, examination, and testing of swallowing, communication, and cognition. Defines patient’s status with clear and specific measures. Forms the basis for planning care, drives and defines the treatment plan, and supports SLP impressions and recommendations. Presents the reader with evidence and rationale for why SLP services are needed. Serves as the primary form of communication between care providers. Assists the clinician to self-reflect, integrate information, and pull the story together; reflects the clinician’s thought process. Provides the patient with education and information about what was found and what is recommended. Meets regulatory agency and institution requirements. Supports billing. Protects legal interests of patient, hospital, and clinician. SLP = speech-language pathologist Re-assessment and Monitoring of Patient’s Status in a Dynamic Clinical Setting Ongoing SLP monitoring and intervention continue after the assessment is completed and is essential in reducing re-admissions, improving patient health outcomes, and expediting an appropriate discharge plan. The SLP may be the health care provider who identifies a decline in the patient cognitive-communicative status that may indicate a new infection or bleed, or may collaborate with the medical team to identify the effectiveness of a medical intervention by tracking improvements, 46 such as improvements in dysarthria and dysphagia in a patient with myasthenia gravis following a new dosage of Mestinon. Dynamic changes in patient condition demand reassessment and potential changes in recommendations. The frequency of follow-up and the length of treatment sessions following an initial assessment are driven by each patient’s clinical condition and treatment needs. Although diagnostic evaluation activities and observation encompass the bulk of the work in acute care, often this work is done over the course of multiple treatment sessions in order to provide the clinician with further information that supports or disputes the initial impressions and findings. A variety of patient-care situations may require follow-up monitoring and/or intervention, such as Decline in medical status: A patient with a frail/critical clinical condition who requires close monitoring of diet tolerance, such as a recently extubated patient with higher oxygen needs who is started on an oral diet that may need to be discontinued if there is any negative effect on the patient’s respiratory or medical status Improvement in medical status: A patient with an acute medical status that is anticipated to improve and stabilize rapidly, such as an acute stroke patient who is seen on the first day after a stroke and is not yet deemed safe for oral intake, yet is expected to stabilize in the next several days, which may allow for initiation of an oral diet SLP intervention is integral to affecting a change in status: For a patient in the midst of a tracheostomy tube downsize/decannulation process, the SLP involvement is essential for speaking valve use; or a patient may need further education and training to independently complete a swallowing strategy or modification that will allow an upgrade to a less-restrictive diet Further testing: A patient with a clinical need for instrumental examination following the clinical swallow evaluation to better understand the swallow mechanism, to assess for aspiration, and to determine safest diet consistency and strategies Neuro-cognitive monitoring: A patient with cognitive-linguistic impairments who needs ongoing monitoring of deficits, monitoring to track recovery, as well as evaluation for predicting rehab prognosis, identifying rehab goals, determining an appropriate rehab setting, and providing family support/patient education Quality-of-life/end-of-life issues: A patient requiring assistance in communicating his or her wishes, collaborating with the social worker to complete a health care proxy, and providing education to the medical team regarding the impact of aphasia on decision-making capacity SLPs must be cognizant of the importance of following their patients after completing initial evaluations when warranted, especially as it relates to their integral role in reducing re-admissions, improving patient health, and expediting an appropriate discharge plan. Advocacy, Patient Management, and Education Throughout the patient’s hospitalization, the ultimate goal is to provide the most effective care, directed toward safe discharge, with the aim of reducing the need for readmission for a post-hospital complication. The SLP therefore must be vigilant regarding the discharge plans for the patient and must be current on the patient’s status, procedures, and progress. Depending on changes in status, the SLP may need to advocate for appropriate levels of rehabilitation, nonoral feeding, palliative care, and changes in method of medication administration, among other issues. Seeking opportunities for regular contact with key health care providers affords the SLP the opportunity to comment on the likely impact of clinical decisions on patient outcome from a communication or swallowing perspective and to ensure that appropriate outpatient referrals are obtained prior to discharge. For example, it is possible that a previously high-functioning professional oriented to the present and general conversation after a traumatic brain injury may benefit from intensive inpatient rehabilitation, rather than home therapy, to maximize function in a short amount of time. Conversely, a motivated and cognitively alert yet frail patient with a long, complex hospitalization due to complications from open heart surgery may lack the reserve for an intensive rehabilitation program. The SLP is charged not only with advocacy regarding current care but also with predicting the most appropriate care for the patient that will promote the most favorable outcome. Having a clear and concise rationale for a particular patient recommendation not only facilitates being heard by the other health care providers juggling multiple patient scenarios but also serves as a means of educating the provider about the issues at hand that could be applied later to other patients. It seems that the most effective manner of advocacy and helping providers understand the purview of the SLP is one example at a time, linked to a particular patient scenario. This promotes relationship building among providers and trust in the SLP’s expertise. Additionally, the SLP’s expertise in communication and aphasia can be helpful to families in the acute crisis after a stroke. The SLP can provide general information on aphasia and recovery, describe improvements that the family can realistically expect, and share community resources available after discharge. 47 The SLP may be an invaluable resource to residents training in an academic medical center by demonstrating at the bedside how best to elicit language and to improve physician-patient communication, which, in turn, may improve the residents’ ability to make an accurate medical diagnosis, to decrease medication errors, and to improve health outcomes after discharge. 48 15.10 Conclusion This chapter describes the role of the medical SLP in acute care, in which clinical management and decision making require consideration of the patient beyond the immediate episode of care. The macro-level decision making of the SLP in the acute-care setting relies on the individual’s medical, specialized, and institutional knowledge superimposed on patients’ and interdisciplinary teams’ goals, in an effort to achieve the desired long-term outcome while ensuring high-quality, efficient, effective, patient-centered, and cost-effective care. As the process of reporting patient outcomes increases in importance in the acute-care setting, the role of the medical SLP has become increasingly relevant. The SLP must remain vigilant and ensure that SLP intervention adds value. The SLP is challenged first and foremost to treat each patient holistically, not just the patient’s communication and swallowing disorder. In addition to including patient preferences and performing evidence-based care, understanding the impact of “whole-body illness” on the domains of concern to the SLP drives relevant and quality patient care. The qualities of astute observation, flexibility of thought and schedule, clear and concise communication skills, compassion, fearless advocacy, teamwork, and collaboration are the hallmarks of excellent care. 15.11 Study Questions Explain the benefits of interprofessional service delivery to patient safety, quality of care, and patient satisfaction. Discuss the unique contributions of SLP practice in the acute care setting as related to assessment and management of speech/language/swallowing/cognitive issues for patients. Differentiate the acute care SLP role from the rehabilitative, palliative, or post-acute focus. Identify at least five key resources needed by the SLP to provide access to information regarding (a) medical tests and procedures; and (b) drugs that affect speech/language/swallowing/cognition. List essential acute care precautions to consider before completing a bedside swallowing evaluation. Differentiate SLP critical questions between acute care and rehabilitation settings? Explain the rationale for implementing both bedside swallowing assessment and instrumental studies? Are there limitations to either approach in isolation? Complete a self assessment of your own skills and knowledge? What gaps do you need to address in order to practice effectively in an acute care setting? How could those gaps be addressed? Appendix 15.1 Types of Hospitals*

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Benefits of Physical, Speech, and Occupational Therapy at a Skilled Nursing Center

A serious hospitalization can have a significant impact on a person’s quality of life and may require additional care at a skilled nursing center, also known as a post-acute care center. Whether you suffered a stroke, live with a chronic illness, or experienced a life-changing fall, this level of care provides each patient with a rehabilitation program intended to help them achieve a successful recovery and regain their full independence. Your healthcare team will work with you to build an Individualized Treatment Plan that involves one or more therapy programs: physical, speech, and/or occupational therapy.

At Prestige Care, our licensed therapy teams are dedicated to working with each resident, their family, and their doctor to develop a care plan that’s best suited for their recovery goals. Upon arrival, an evaluation will be conducted to determine which therapy program is optimal for each individual’s medical needs. Our goal with this level of care is to help each person transition successfully from hospital to home.

It is important to understand the critical role a post-acute therapy program plays in improving a person’s independence and reducing their length of stay. In addition to stimulating muscle recovery and cognitive health there are many more benefits to physical, speech, and occupational therapy at a skilled nursing center.

Physical Therapy

Physical therapy is essential in improving many different aspects of a person’s health and provides a variety of benefits for people who are recovering from a surgery or injury that has impacted their mobility and strength. This level of care is pivotal in restoring a person’s functional mobility, reducing inflammation, and improving balance and strength to prevent the risk of a fall and/or further complications.

While physical therapy can help a person regain their motor skills and increase physical range of motion, it can also be beneficial in managing chronic pain as a result of a hospitalization. This allows for a more comfortable and accelerated recovery which can lead to a smoother transition back to their independent lifestyle.

The goal of a physical therapy program is to improve a person’s physical challenges and overall quality of life. This is accomplished through a series of educational resources, therapeutic techniques, tailored exercises, and assessments such as Short Physical Performance Battery (SPPB) Score , Gait Speed and 6 Minute Walking Test (6MWT).

Physical therapy can be beneficial for a wide range of medical needs and is important to consider if you have limited mobility, significant muscle loss after an injury, or experience poor balance that can make you more susceptible to falls or injury.

Speech Therapy

If you or a loved one experience challenges associated with swallowing that affects your independence or have recently suffered a stroke or serious medical event that has impacted your communication skills, your healthcare team may recommend speech therapy at a post-acute care center prior to returning home.

Speech therapy at a skilled nursing center can have a positive outcome in a person’s overall recovery. It can help resolve problems with swallowing or eating, and improve communication challenges in speaking, reading, writing, memory retention, and verbal expression. This may include focusing on identifying vocal cues, verbal repetition, or practicing mouth movement techniques. This level of care is essential in improving cognitive function and can increase a person’s ability to communicate and understand clearly in social settings.

Speech therapists will also often collaborate with the dietary team to develop a customized diet plan for patients that may have difficulty with swallowing or eating.

Speech therapy not only increases a person’s cognitive health, but also their emotional health. It can bring a person a sense of confidence as their communication skills are advancing and they are able to express themselves with loved ones.

Occupational Therapy

If your independence has been impacted after a serious hospitalization or injury, you may require occupational therapy at a post-acute care center to help you regain your functional skills in completing daily tasks. This type of therapy program focuses on helping patients refine their motor skills, improve hand and upper extremity function, and achieve independence in activities of daily living (ADL) such as eating, bathing, and dressing to ensure they can return home to their active lifestyles.

Occupational therapy at a skilled nursing center not only provides exercises to improve a person’s physical health, but also educational resources on managing partial or permanent loss of function from the result of an injury or chronic illness. Your therapy team will work with you to ensure you have the tools you need in preparation for your return home. This may include ongoing evaluations and assessments such as SLUMS and ACL to evaluate your independence in performing activities of daily living.

If your independence has been affected after an injury, it is normal to feel overwhelmed and have a sense of frustration as you are working to regain your self-sufficiency in everyday tasks. Occupational therapy not only benefits your physical health, but also your mental well-being. As you are improving your functional skills, you will begin to notice an increase in confidence as you are able to complete tasks on your own.

Therapy at Prestige Care

Whether you require physical therapy to enhance your strength and mobility, speech therapy to improve challenges with speaking, swallowing, or eating, or occupational therapy to help regain your independence in activities of daily living, Prestige is here to help. We work with each resident and their physician to determine their individualized therapy plan and conduct ongoing evaluations to ensure they are receiving the care they need for an optimal recovery.

Our experienced therapy teams use a data-driven analytical approach and proven assessments to help increase positive recovery outcomes, dramatically decrease the risk of future complications, and improve overall functional skills.

Our speech, physical, and occupational therapy programs are intended to help each patient regain their independence and prepare for their transition home. Contact a Prestige Skilled Nursing and Rehabilitation Center near you to learn more about our therapy programs.

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The importance of physical fitness to cognitive health, when cognitive decline might require senior living, what to expect from memory care at a skilled nursing center.

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The Role of the SLP in a Skilled Nursing Facility (SNF)
Speech-Language Pathologists (SLPs) play an important role in a Skilled Nursing Facility (SNF). SLPs assess and treat patients with a wide variety of deficits, including, but not limited to, dysphagia, cognition, speech and/or communication difficulties. According to ASHA, approximately 7.
The Role and Impact of Speech Therapy
The Benefits of Speech Therapy: Speech therapy offers numerous benefits beyond improved communication skills. For individuals with communication disorders, it can enhance social interactions, academic performance, vocational opportunities, and overall quality of life. By addressing communication challenges early and effectively, speech therapy ...
In brief: What is speech therapy?
Speech therapy can help people who have difficulty speaking to communicate better and to break down the barriers that result from speech impediments. The goals of speech therapy include improving pronunciation, strengthening the muscles used in speech, and learning to speak correctly. Speech therapy can be used for a lot of different speech problems and disorders, from smaller problems like a ...
5 Top Tips to Thrive as an SLP in the Skilled Nursing Setting
Speech-language pathologists (SLPs) often work at skilled nursing facilities (SNFs), providing short-term rehab care and ongoing treatment for long-term care residents. Some of the SLP treatments most frequently seen in the SNF setting include care for dysphagia, cognitive-linguistic functioning, and speech-language deficits. I've worked in more than 40 SNFs.
Speech Therapy: Uses, What to Expect, Results, and More
A speech-language pathologist (SLP) can help you with speech, language, and swallowing. They provide speech therapy to children and adults who may have speech or language disorders. People with certain medical conditions may also benefit from speech therapy. Medical conditions that may cause speech or swallowing impairment include traumatic ...
Speech Therapy: What It Is & How It Works
Speech therapy is treatment that improves your ability to talk and use other language skills. It helps you express your thoughts and understand what other people are saying to you. It can also improve skills like your memory and ability to solve problems. You'll work with a speech-language pathologist (SLP, or speech therapist) to find ...
Knowledge and Perception of Registered Nurses Regarding the Scope of
1. Introduction. A speech-language pathologist (SLP) is a member of the healthcare team who primarily performs the assessment, evaluation, and treatment of swallowing disorders [].Speech-language pathology therapy (SLPT) prevents and corrects language, speech, voice, and fluency problems in patients [].Thus, assessment and intervention for patients with speech problems are primarily the ...
Speech, language and communication impairments
The nurse can refer directly to speech and language therapy or to a GP, and can also guide the patient to information to help them take things forward themselves. For more information on speech language and communication disorders and how to access speech and language therapy, go to The Royal College of Speech and Language Therapy (see Resources).
What Is a Speech-Language Pathologist (Speech Therapist)?
A speech-language pathologist (SLP) diagnoses and treats conditions that affect your ability to communicate and swallow. SLPs work with people of all ages. As experts in communication, these specialists assess, diagnose, treat and prevent speech, language, voice and swallowing disorders from birth through old age.
SLPs in Long-Term Care
SLPs in Long-Term Care. According to , approximately 7.6% of ASHA-certified SLPs work in skilled nursing facilities. These SLPs are presented with a varied caseload that has become more acutely ill than in the past. They also face numerous staffing and reimbursement challenges that are unique to this setting.
What Is a Speech Pathologist?
Schools: Speech therapists working in schools help children with speech disorders learn to overcome their communication challenges. Nursing homes: Speech therapists in nursing homes help patients with dementia or communication issues caused by other conditions like stroke learn communication strategies. They also work with staff on ways to help residents communicate more effectively.
Speech therapy: For adults, kids, and how it works
Speech therapy for adults. An SLP can use several different techniques as part of adult speech therapy. These include: Social communication: The SLP may use problem-solving, memory activities, and ...
Speech and Language Therapy
Speech and language therapy or pathology is a type of health care that addresses communication and swallowing disabilities and issues. Professionals in this field are highly-trained experts in working with both children and adults who struggle to speak, communicate, comprehend or use language, or eat and drink because of any number of conditions and disabilities.
Types of Speech Therapy: Techniques and Approaches
A speech-language pathologist can use different types of speech therapy to help people with problems related to: Fluency (e.g., stuttering, and cluttering) Speech (e.g., articulation) Language (e.g., ability; comprehension of spoken and written language) Cognition (e.g., attention, memory, ability to solve problems)
What Is a Speech-Language Pathologist (SLP)?
A speech-language pathologist (SLP), also known as a speech therapist, is a health professional who diagnoses and treats communication and swallowing problems. They work with both children and ...
Speech-Language Therapy Services
During your initial visit, you will discuss your goals for therapy, and the speech-language pathologist will evaluate your speech-language concerns. After the evaluation, the pathologist will diagnose the concern and develop an individualized treatment plan with you. Your therapy team will provide education, treatment, intervention, management ...
PDF SKILLED NURSING FACILITY
SKILLED NURSING FACILITY. This is a screening tool to be used as a guide for determining the need for referral to speech-language pathology services. Please note that this is a referral tool only and is to be used by non-SLP providers to plan for necessary follow-up. It is not to take the place of a comprehensive assessment of thinking ...
Speech Assessment
Speech is a communicative skill that enables us to understand each other and to interact. It becomes a means of communication, allowing us to share ideas, beliefs, and opinions. When this process is disrupted, and the normal flow of receptive and expressive aspects of speech is compromised, a speech assessment is carried out to assess a disturbance in any part of this process. Disturbances of ...
The Effectiveness of Speech and Language Therapy for Poststr ...
Nursing staff have a key role in supporting people with aphasia from the acute stages of stroke to long-term management in the community. Having knowledge of aphasia and being able to discuss with patients and family what they may expect from therapy is an essential part of providing patient-centered care.
Speech-Language Pathology in the Acute Inpatient Setting
The new patient-centered model of acute-care SLP practice includes four essential dimensions: (1) assessment and management of swallowing, speech, language, and cognitive components; (2) identification of features of the patient's current or predicted status or behavior that contribute to any concerns about safety, quality of care, or cost; (3) the patient and family's values and goals for ...
Benefits of Physical, Speech, and Occupational Therapy at a Skilled
Speech therapy at a skilled nursing center can have a positive outcome in a person's overall recovery. It can help resolve problems with swallowing or eating, and improve communication challenges in speaking, reading, writing, memory retention, and verbal expression. This may include focusing on identifying vocal cues, verbal repetition, or ...
Documentation in Health Care
Documentation is a critical vehicle for conveying essential clinical information about each patient's diagnosis, treatment, and outcomes and for communication between clinicians, other providers, and payers. Documentation should proactively answer questions that payers ask about services, such as the following:
Speech Therapy vs Occupational Therapy: 3 Key Differences
Speech and occupational therapy professionals work in rehabilitation— both professions aim to improve the lives of their patients. Additionally, each role often requires compassion, an eye for detail, and strong communication skills. In the career debate between occupational therapy vs speech therapy, the key difference is their areas of ...