BEST Dysphagia Management Services, Inc.

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BEST Dysphagia Management Services, Inc.
Barriers to Functional Dysphagia Management In
the SNF Setting

• Carol G. Winchester
• MS, SLP, CCC
• President

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It starts at the beginning!

• Accurate Historical Patient Information is
  difficult to find or missing
• Face Sheet
• Patient Hospital Notes
• Consultations
• Time Barrier in Reporting

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It starts at the beginning!

• Solution
• Interview the family to assure accuracy in
  reporting
• Look at the patientis this the same patient as
  described?
• Check back later in the week to confirm initial
  impressions
• Check with medical records to see if the chart
  was thinned

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Misinformation is dangerous!

• One Patient, Four Admissions
• Diet changes missed
• Diagnosis changed
• Consistency in care absent
• It is the responsibility of every therapist to
  know what and why you are treating the patient
• Without accurate historical reporting.is this
  possible?

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Misinformation is dangerous!

• Soultion
• Review the chart again after each admission
• Ask of the chart has been thinned
• Interview the family again to find out what has
  changed
• If a patient comes from another facility.assume
  that information is missing!
• When something does not make senseASK ASK ASK!!!

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One Patient4 SNF Admissions No
Instrumentation for Dysphagia

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Stay 1

• Patient admitted to the Nursing home with a
  diagnosis of pneumonia.
• Patient was on O2 at 3L.
• Patient stayed 36 days
• Patient returned to the hospital with pneumonia .
• Patient was on a honey thick liquid consistency
  during stay number one.

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Costs associated with Stay 1

• Liquid thickener per month 60.00
• Therapy Costs at Ultra High RUG 3240.00
• Antibiotic Treatment 336
• Respiratory Drugs 73.44
• Oxygen _at_ 3L 1260
• Total Pneumonia Costs 4969.44

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Stay 2

• The patient returned to the facility for 88 days
• G-tube placed for nutrition and hydration
• Placed in a specialty bed for decubitus.
• On a thickened liquid of a pudding thick
• Patient fell and fractured a hip
• Returned to the hospital for repair.

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Costs associated with Stay 2

• Liquid thickener per month
• 90.00
• Therapy Costs at Ultra High RUG 5760.00
• Antibiotic Treatment 336
• Respiratory Drugs 122.40
• Oxygen _at_ 3L 2100.00
• G-Tube Pump 266.64
• Wound Care 15,400.00
• Specialty Beds 1125.00
• Total Repeat Pneumonia Costs 25,200.04

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Stay 3

• FX Hip repaired at the hospital
• Patient returned to the facility with a diet
  order including thin liquids.
• Patient stay 13 days
• Returned to the hospital with DX of increasing
  congestion and dehydration.

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Costs associated with Stay 3

• Itemized Costs Associated with Stay 3
• DX of Fx Hip
• Liquid thickener per month0. ( p on thin
  liquids again)
• Therapy Costs 0
• Antibiotic Treatment 168.00
• Respiratory Drugs 26.52
• Oxygen at 3L 455.00
• G-tube 0
• Wound Care 2275.00
• Specialty Bed 0
• Total Additional Costs 2924.52

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Stay 4

• Diagnosis upon return to the facility was
  Bronchitis.
• Patient was placed on a pudding thick liquid for
  the course of this stay.
• Pt Died on day 61 of Stay 4

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Costs associated with Stay 4

• Itemized Costs Associated with Stay 4
• Dx of Bronchitis
• Liquid thickener per month120
• Therapy Costs 4270
• Antibiotic Treatment 168.00
• Respiratory Drugs 61.12
• Oxygen at 3L 1050.00
• G-Tube 0
• Wound Care 10,675.00
• Specialty Bed 1525
• Total Additional Costs 33,094.00

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He Said, She Said!

• Family dynamics are a powerful source of
  happiness and stress
• Understanding your patients
• reaction to family situations can
  inhibit rehab potential
• Sometimes the patient isnt the sickest one in
  the group dynamic.

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He Said, She Said!

• Solution
• Listen and Learn from the interactions you
  witness.
• Incorporate the dynamics into the therapy
  recommendations, taking note of the caregivers
  personality.
• A recommendation is only as functional as the
  person charged with its use and/or supervision
• The patient may not have been the patient prior
  to the medical incident.
• Plan to try out your recommendations!

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Know Your Audience!

• Its hard to have a battle of wits with an
  unarmed man!
• Aspiration is an old persons best friend
  (anonymous DON)
• Speech therapy? He can talk just fine!
  (anonymous nurse)
• Speech? You people put everyone on thickened
  liquids, I can do that! (anonymous physician)

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Know Your Audience!

• Solution
• Arm yourself with information
• Inservice, Inservice, Inservice
• Visibility, Visibility, Visibility
• Praise, Plead, and Perform!

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You cant get water from a rock!

• Every SNF is different in some aspects, small and
  large!
• Dietary goals, policies, procedures and theories
  are a reality in your facility.
• Policies are written at the corporate level and
  take months of negotiations to complete.

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You cant get water from a rock!

• Solution
• Become a part of the team
• Be interested and sincere
• Be cognizant of the cost of dietary care
• Pick your battles at first!

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We are the only SLPs in the facility!

• SLPs are the experts in dysphagia management for
  the SNF.
• Some realities
• Other disciplines are not as interested as you
  are in dysphagia
• Very few people understand how precarious the
  anatomy of the swallow really is
• Physicians rely on your expertise
• Nursing may cringe every time you impose another
  constraint on how they perform their work
• 7.00 per hour help spends the most time with any
  patient on any given day

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We are the only SLPs in the facility!

• Solution
• Dont try to make SLPs out of everyone in the
  building
• Disseminate information in a neat, need to know
  package
• Dont be shy about your credentials
• Praise when its right, go to the supervisor when
  its wrong..
• Never, Never, Never discipline anyone yourself.
  Its not your job!

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Patient and Facility Culture

• What is the culture of the facility owners?
• Geographically, is there an identifiable culture?
• Is this a city or a small town?
• Are you from a town of similar size and culture?
• How do you modify your behavior to fit in?
• Why does it matter?

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Patient and Facility Culture

• Solution
• Learn about the community in which you work
• Are there local Rotary or Kiwani Clubs that would
  donate to your program?
• Take home the local paper now and then and try to
  get a feel for the issues important to the
  community
• Knowing how things work can make the difference
  between a so-so program and one that focuses on
  quality patient care
• Why does it matter? These people had vibrant
  lives before illnessrespect that!

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Religious Variables

• Even though its politically incorrect to discuss
  it.religious values matter in patient care
• What is the religious culture of the area? How
  does it affect therapy goals? Diet modifications?
  Compensatory strategies and equipment?
• Catholic?
• Jewish?
• Mormon?
• Amish?

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Religious Variables

• Solution
• Ask questions if you are unsure of culture and
  expectations
• Make sure to adhere to the peculiarities of their
  religious practices
• Dont assume that it no longer matters!

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The American Diet

• Something close to 80 of men over the age of 65
  have GERD
• Women are fast approaching that figure
• Stress of modern life
• The good ol American Diet

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Monilial Esophagitis
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Esophageal Candidiasis
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Reflux Esophagitis II
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Reflux Esophagitis III
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Reflux Esophagitis IV
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Esophagitis Squels / Stenosis
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Zenkers Diverticula
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Sliding Hiatal Hernia
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The American Diet

• Solution
• Understand the signs of reflux
• Know the function of GERD and the associated
  results
• Be prepared to speak to the nurse/physician as to
  why reflux management is important to dysphagia
  management
• Follow up in 3-4 weeks for results

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Pharmaceutical Effects

• Dysphagia can sometimes be the result of
  medications for the primary diseases
• Pharmaceutical effects can be mysterious to both
  the patient and the therapist
• The effects of medications can be transient
  throughout the day

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Pharmaceutical Effects

• Solution
• Become Educated!
• New book Drugs and Dysphagia by Drs Lynette
  Carl and Peter Johnson
• Chart reviews are VITAL!
• Repeated visits to the medical chart as
  medications change
• BE INFORMED and STAY INFORMED!

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Personality!

• Reality Sometimes you cant teach and old dog
  new tricks
• A non-compliant personality will not suddenly
  become compliant
• A man who has a lifelong hatred of women will not
  perform well with a female therapist
• A woman who is intimidated by men will react
  differently with a male and female therapist
• Depression can, and will affect therapy
  negatively

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Personality!

• Solution
• Interview family
• Dont assume that depression equals
  non-compliance
• Give the patient time to react to the illness
• Work WITH the personality, dont try to change
  it.
• Never reprimand for personality traits.

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Conclusion

• Functional Dysphagia Management is more than an
  evaluation and identification of disease
• Other issues can and will negatively affect the
  outcome unless you incorporate them into your
  realm of understanding

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Handouts

• Handouts can be downloaded from the BEST website
  and used to inservice your facilities!
• www.BESTDMS.com
• Available May 30th