By: Rinki Varindani Desai, MS, CCC-SLP, University of Mississippi Medical Center
Long-term care (LTC) includes a wide range of medical and support services provided over an extended period of time to people who are unable to independently complete activities of daily living (ADLs). LTC facilities also may be referred to as nursing homes, skilled nursing facilities (SNFs) and/or assisted living facilities (ALFs). LTC and SNF are terms often used interchangeably in the health care field.
There are currently about 1.5 million people in 16,000 skilled nursing facilities in America. By 2030, this number may be as high as 2.6 million, according to the Centers for Medicare and Medicaid Services (CMS).There is a significant need for therapy services provided by speech-language pathologists (SLPs) in LTC settings, which will only grow in the years to come.
LTC facilities do not just house the frail elderly. In past years, a SNF was a place that provided care for people who were often too frail or "sick" to be considered candidates for any type of rehabilitative treatment. SNFs had the stigma of being a place where people went to live out their final days, often with no hope for living with much quality of life. Today, in addition to meeting health and social needs, LTC facilities also provide rehabilitative services to individuals who demonstrate potential for improvement in independent functioning of daily living skills. Data shows that LTC rehabilitation programs can be very successful in allowing individuals to improve functioning enough to return to a more independent setting.
The rehabilitation provided in LTC or SNF settings is often referred to as subacute or post-acute care. Subacute rehabilitation is less intense than acute rehabilitation. Patients in a subacute facility generally only receive one or two hours of therapy per day, and it is usually a combination of physical, occupational, and speech therapy services.
The need for long-term care can be instantaneous, such as after an acute hospitalization, stroke, or heart attack. Generally, however, it develops gradually as individuals age and become frailer or as an illness or disability worsens. Different types of long-term care are available within community-based care organizations and care communities, including:
Temporary long-term care (need for care for a few weeks to months) due to:
- Rehabilitation from a hospital stay
- Recovery from an acute illness
- Recovery from injury
- Recovery from surgery
- Terminal medical condition
Ongoing long-term care (need for care for many months or years) due to:
- Chronic medical conditions
- Chronic severe pain
- Permanent disabilities
- Ongoing need for help/supervision with activities of daily living
- Cognitive impairments associated with advanced illnesses such as those caused by brain
injury or dementia
A speech-language pathologist who provides services in a long-term care setting will likely be addressing communication, cognition, and dysphagia deficits that may be due to a number of underlying diagnoses. According to the American Speech-Language-Hearing Association (ASHA, 2017), the most commonly treated diagnosis categories in long-term care are:
- Cerebrovascular accident (CVA)
- Mental disorders
- Respiratory disorders
- Central nervous system disorders
- Other neoplasms
ASHA (2017) further reports this breakdown of specific speech-language pathology-related disorders seen in a LTC setting: swallowing (72%), memory (27%), problem-solving (20%), expressive language (20%), and language comprehension (19%)
A therapy team in LTC and subacute rehab settings typically consists of rehab techs, therapy assistants, and therapists from each therapeutic discipline (OT, PT, and SLP) to carry out patient care. Overseeing the whole operation will be a clinical supervisor or director of rehabilitation (DOR). The SLP team may be comprised of full-time, part-time, and PRN staff.
Patient caseloads vary in relation to size and location of facility. Once a referral is received, initial evaluations are scheduled and completed in a timely manner, typically within the first 24 to 48 hours. A plan of care (POC) is established by the evaluating SLP. Patients are typically treated three to five times a week for approximately four to six weeks. These recommended figures establish a certification period and are highly dependent on the referring diagnosis and severity level of the patient. At the end of a certification period, the patient is re-evaluated.
When working in a LTC setting, an SLP’s daily schedule will typically involve the evaluation of new patients, re-evaluation of current patients, and completing treatment sessions. Other daily responsibilities will include documentation, family counseling, meetings, and inter-disciplinary collaborations.
Procedures often performed by the SLP in a long-term care setting:
- Speech-language-cognition evaluations
- Clinical and/or instrumental swallow evaluations
- Speech-language-cognitive therapy
- Dysphagia therapy
- Voice therapy
- In-services and education
Diagnoses often seen in a long-term care setting:
- Neurodegenerative disorders (dementia, Parkinson’s, multiple sclerosis)
- Non-traumatic brain injuries (CVA, tumors, infections)
- Traumatic brain injuries (falls)
- Post-op head and neck surgeries (cancer)
- Voice cases (Parkinson’s, muscle tension dysphonia, dystonia, etc.)
One of the most common diagnoses seen in the LTC setting is dementia. A common misconception in regard to rehabilitation in the geriatric population is that patients with dementia cannot benefit from skilled speech pathology services. As SLPs, it is our responsibility to evaluate and stage dementia patients so that other caregivers and families can engage in quality communication with these patients. We also play a critical role in maximizing their swallow function and quality of life, particularly as the disease advances and patients are at the end of life. There is no cookie-cutter treatment plan that can be applied to all patients. Remember that each patient is different; they each require different levels of care and focus in various areas.
Opportunities for SLPs to care for the growing number of individuals in LTC settings are growing quickly. The SLP who is considering practicing in the long-term care environment should have a good understanding of the population, of common diagnoses, and the challenges unique to this environment related to reimbursement, documentation, and productivity. Working within this setting can be very stimulating to the speech-language pathologist who loves the challenge of problem-solving, recognizes the benefits of interdisciplinary evaluation and planning, and appreciates the rewards of seeing a person return to a higher level of function or stabilizing after a decline in health.
Additional resources for SLPs getting started in long-term care can be found here: https://www.asha.org/slp/healthcare/start_long/.