Greetings, Patient Driven Payment Model

Hello, Patient Driven Payment Model.  Its nice to meet you!  To an industry wondering if and when the RCS-1 System was coming, it looks like that question has been answered. Change is coming, but its going to look a bit different than we were expecting.

On Friday April 27th, CMS announced that the Patient Driven Payment Model (PDPM) has been proposed to replace the RUG-IV System effective October 1, 2019.  It appears that many of the concepts of RCS-1 remain, primarily an end to a reimbursement system driven by therapy minutes.  PDPM includes what looks to be some very SNF friendly improvements from an administrative / MDS standpoint.

While we anxiously await more information from CMS and more insight from industry experts, all indications are that reducing the near 140,000 payment combinations associated with RCS-1 was a priority.  The PDPM contains 80 % less combinations and appears, on the surface, to streamline the process considerably.  Among the other concerns with RCS-1 was very “loose” guidelines around delivery requirements for Physical and Occupational Therapy, and their controversial combination into one group.  Initial feedback suggests that PDPM has addressed this issue.

One more piece of exciting news is the inclusion of an $850 million-dollar payment increase for Fiscal Year 2019.

Now it will be time to dig in, analyze the information, figure out how PDPM will affect operations and put the systems in place for a smooth transition over the course of the 17 months.  CMS is collecting comments on its proposals until June 26 of 2018.

In addition to the SNF PPS proposed rule, CMS also released updates to the prospective payment systems for inpatient psychiatric facilities, inpatient rehabilitation facilities, and wage index and payment rates for hospice.

We’d love to hear your thoughts!  Feel free to share below.


Speech Therapy and Rehab: With or Without RCS-1 (Part One)

On Friday April 20th, Michael Webb and I presented to the membership of the Genesee Health Facilities Association in Rochester, NY during their monthly meeting. 

When we were originally asked to speak, we had planned on presenting about the impact of Speech Therapy on RCS-1.  However, during the recent CMS Open Door Forum, John Kane from CMS informed the listeners that the timeframe for RCS-1 was still yet to be established and CMS was still considering the multitude of public comments that had been received.  In light of this news, we needed a new plan for this presentation.

We figured that the Administrators and Directors of Rehabilitation in attendance would like to hear about:

1.       What exactly happened on the CMS Open Door Forum

2.       What tasks should your Speech Therapists be performing on a daily basis at your SNF

3.       Insight into preparing for RCS-1, if it does become implemented

4.       Some new ideas if we are to continue in a RUGS world

 After the CMS Open Door Forum, the question everyone is asking regarding RCS-1 is “Will it Ever Be Implemented?”  Our answer is: “We don’t know yet…” and we don’t.  Here’s why:

On one hand, many key stakeholders in Washington DC strongly oppose a reimbursement system so influenced so heavily by the delivery of therapy minutes.

On the other hand, the RCS-1 system and its near 140,000 different permutations and outcomes seems far too complicated, leaving us all at a unique crossroads.

The IMPACT Act called for MedPAC to draw up the framework of unified payment system for a multitude of Post-Acute providers.  Perhaps the RUGS System will be with us until the Unified Post-Acute Payment System is here, which could be as early as 2021?

Don’t cross off RCS-1 from your “to do list” just yet. We are all curious how things will unfold over the coming months. 

Providing speech therapy service for skilled nursing facilities has many unique nuances. In our next edition, we will take a closer look at the tasks that great Speech Therapists performing at SNFs to enhance the quality of life for the residents.

We’d love to hear your thoughts or comments.  Feel free to comment below.


Improving Outcomes Using FEES – A Case Study

Flexible endoscopic evaluation of the swallow (FEES) testing has been a fantastic tool to help diagnose dysphagia in a variety of settings.  We have used this tool to recommend the appropriate food and fluid consistency in literally thousands of patients in the SNF setting over the years.  We use FEES to assess the appropriate need for postural changes as well as the effectiveness of several compensatory strategies. 

 The following is an example of a less scientific single study subject example of the effectiveness of treatment for a patient with severe dysphagia.  TC is an 83-year-old male who presented with TIA, COPD, pneumonia, dysphagia, asthma and A-fib.  Upon his arrival to a skilled nursing facility, a bedside swallow evaluation was conducted, and TC was placed on pureed foods with honey liquids. 

 They treatment plan for TC was five day a week dysphagia treatment with goals to increase strength and tone.  Initial FEES testing was conducted to rule out aspiration and assess for a possible diet upgrade.  That test noted significant aspiration of both foods and fluids with pooling of residue to bi-lateral pyriforms.  The picture below shows the severity of TC’c dysphagia.  The green that you see is food and fluid dyed for easier visibility.

Working in collaboration with the treating clinician, who was present for the study, a new treatment plan was decided upon that included increasing pharyngeal strength and tone and the use of NEMS as a treatment modality to increase laryngeal elevation.  A follow up study was scheduled for four weeks to assess any progress.

Four weeks later, the follow up study was performed, and the results were clear and evident.  Significant progress was evident with increased strength and tone noted.  Pharyngeal squeeze was notably more pronounced after four weeks and as the picture below shows residue was significantly decreased.  

TC was upgraded to a mechanical soft and nectar consistency and is continuing to work with the clinician to increase safe PO intake and increase the diet to regular and thin liquids. 

 This was one, albeit an outstanding, example of a great clinician dedicated to increasing the quality of life of her patients.  We were just lucky enough to be apart of the care and capture it with a camera.  Having these cases documented allows clinicians to see the progress that is made and allows clinicians to feel comfortable in advancing the patient’s diet while mitigating the risk of aspiration pneumonia, and potential re-hospitalization.

Want to learn more about FEES testing in the SNF setting?  Want to chat about Speech Therapy, Rehab, or perhaps something else? I’d love to hear from you!  

Understanding The 7 Types of Aphasia

As a Graduate Student, I became fascinated by learning the different types of Aphasia.  Understanding the different types,  provide the building blocks to effective treatment.

Listed below are the 7 different types of aphasia:

1.        Broca’s aphasia

2.        Transcortical motor aphasia

3.       Global aphasia

4.       Wernicke’s aphasia

5.       Transcortical sensory aphasia

6.       Anomic aphasia

7.       Conduction aphasia

Out of these 7 types of aphasia, they can then be broken down by fluency (fluent or non-fluent) and then furthermore by ability to repeat words and auditory comprehension skills. Personally, that’s when I think it can get confusing because once the categories are separated by fluency, the remaining aphasias have a lot of common presenting characteristics.

So while I was in graduate school at Adelphi, I created a graph from my notes in order to understand and remember the very distinct characteristics amongst the types of aphasia.

The graph is provided for your enjoyment in the link below and hopefully help you help your patients in the future!


If you have any questions or comments, please free feel to e-mail me or write them below in this blog.  I’d love to hear from you.

About the Author:

Originally from Coral Springs, FL Britney Minutillo, SLP-CCC is a graduate of Penn State University and Adelphi University where she received a Master of Science degree in Communication Disorders: Speech-Language Pathology. Britney joined the team at Language Fundamentals in 2017 in the medical speech pathology field in Skilled Nursing Facilities and subacute rehab centers  providing a variety of speech/language, cognitive communication and dysphagia evaluations and treatments. She is fluent in American Sign Language.

Are Women’s Soccer Players More Susceptible to Traumatic Brain Injuries?

Two subjects that are near and dear to my heart are soccer and speech language pathology, and they have intersected in my life in a major way. I started playing soccer from the tender age of 4, went on to play on a premiere travel league in middle school and high school, made the Olympic Development Program in high school, and then division I soccer in college. Never did I think soccer would crossover into my profession, but as the incidences of concussions or TBI’s increased in the female population for soccer, this peaked my interest to say the least. 

 Some may be confused as to why there is such an increase in TBI’s with females who play soccer, because after all, isn’t soccer mainly played with your feet? Yes, however, there is one aspect that’s played with your head. It’s called “heading”. I practiced heading the ball with my dad at home, during practice, and also on my own, determined to not be a “sissy” on the field. Little did I know how much heading the ball and head injuries would plague me and females in general who play soccer, especially if performed incorrectly. A study performed by the Society for Neuroscience conference in Washington D.C., indicates that female soccer players may also sustain more brain damage from heading the ball compared to male players.  

 According to another study done by the Albert Einstein College of Medicine in New York, found that after scanning almost 100 brains of male and female amateur soccer players, of which the researchers matched the images with each volunteer’s age and how many times they headed the ball in the last season, found that the female players showed damage in more regions of the brain’s white matter than with their male counterparts.

 “While American football has been both scientifically and colloquially associated with the highest concussion rates, our study found that girls [who play soccer] may face a higher risk,” said Wellington HSU, MD, professor of orthopedics at Northwestern University’s Feinburg School of medicine. The question is, “why?”. Why are more females experiencing concussions rather than males? At first it was believed that women were reporting concussions more often than men, this was deemed to be inaccurate. The question continues to still stand today and researchers are still trying to find the answer.

High profile female soccer players, Brandi Chastain, Abby Wambach, and Megan Rampinoe, have all agreed to donate their brains for concussion/TBI research, in hopes that one day we will be able to find the answer, so that females can play sports without the fear of severe repercussions. 

 A lot of times people have a brain injury and don’t realize they have one, here are some symptoms to help identify when you should contact your doctor: 

  1. headache
  2. blackout, fatigue, or poor balance
  3. disorientation or confusion
  4. sleep disturbances or sleepiness
  5. nausea or vomiting
  6. irritability or mild depression
  7. tinnitus (ringing in the ears)
  8. sensitivity to light

Got questions or comments?  I’d love to hear your thoughts.

 Follow my blog: or on Instagram Bad_lemons

About the Author:

Caroline E. Plank M.Ed., CCC- SLP is a Regional Manager for Language Fundamentals, Inc. in New York City.  Originally from New Rochelle, NY, Caroline is a graduate of Old Dominion University, where she lettered in Women’s’ Soccer, and the University of Virginia. She will be competing in the New York City Marathon in 2018 and the Boston Marathon in 2019








RCS-1: Just a Fault Start or Over Before It Begins?

The Skilled Nursing Facility industry has been preparing for Resident Classification System (RCS-1) since last Spring, when the Advanced Notice of Proposed Rulemaking outlined a new Medicare Part A reimbursement system to replace the existing RUG IV system.

Stakeholders from Washington DC, who felt the RUG system had disproportionate incentives for SNFs to provide excessive therapy minutes to enhance reimbursement, have been advocating for a replacement to the RUG system for some time.  RCS-1 appeared to be the answer to their prayers. By creating a system focused on the clinical condition of the resident, the industry would move away from a system heavily based on resources utilized (first two words in RUG), specifically minutes of therapy.

During the Skilled Nursing Facility (SNF)/Long Term Care (LTC), Open Door Forum held on Thursday, March 8, John Kane, the skilled nursing team lead for CMS, said the agency continues to review and analyze the “significant number of comments” received by his office.  Therefore, CMS has not established a timeline for the implementation of RCS-1.  Maybe the near 140,000 potential RCS-1 rate outcomes were a little much?

In speaking with attendees at the recent 49th Annual New York Chapter of the American College of Health Care Administrators, they are currently facing a multitude of challenges including staffing shortages, improving Five-Star ratings and a new survey process.  Preparing for payment reform has also been near the top of that list.

So, can we expect to see RCS-1 in the FY 2019 SNF Proposed Rule next month? Suddenly, that seems like a longshot. Will RCS-1 be squashed in its entirety on our way to the Unified Post-Acute Payment System being planned by MedPAC for a 2021 implementation? That is a definite possibility. Or perhaps RCS-1 will still happen at a date later than October 1, 2018?  Don’t be surprised at that one either.

Many industry stakeholders (including the Speech Therapy profession 😊) have been excited RCS-1.  For now, we shall all wait and see…..


Questions about RCS-1, Speech Therapy Operations, Rehab or perhaps something else?  We’d love to help.

Swallowing Problems from the Outside Looking In: Friendly Perspective from a Regular Person

Since joining the team here at Language Fundamentals, just 2 short months ago I think I have heard the words “dysphagia” and “swallowing therapy” more than I have in the last 20 years!

Every time I hear those words, I subconsciously revisit some challenges that I faced earlier in my life. I recall vividly the first time I had food “stuck in my throat” back in 1993, and every time since then.  Thankfully on each occasion I could still breathe, however the panic and uncertainty that set in was alarming. Eventually the issue resolved itself and I was able to breathe a big sigh of relief.  Nonetheless, I remember each and every time this has happened during my adult life and every time something similar happened to a family member.

While an esophageal dilation procedure can be highly effective it is not a lot of fun, unless you enjoy tasting spray paint as it hits the back of your throat before drifting off to sleep.  I’ve had this procedure 3 times, with the most recent being in 2011, and knock on wood, things have been good ever since.

Each time I hear the word dysphagia and I think of a senior citizens living in SNFs, I feel for them and am grateful for Speech Language Pathologists, Dieticians, Nurses, and Physicians who want to help improve the quality of life of these folks during their golden years.  With the risk of aspiration and aspiration pneumonia being so real, receiving timely & professional medical care is critical.

For those younger folks, or middle aged guys like me, hopefully you can benefit from the following tidbits.  Remember, I am not a clinician, just a guy with some life experience.

  1. Be mindful of the effects of acid reflux. Some foods produce more acid than others, which has a way of creeping up the esophagus and causing all kinds of irritation.  Control the acid reflux through your diet, and life will be easier.
  2. Take your medicine. It helps!  Just be certain to take it at the physician recommended dose.
  3. Be mindful of family history. Doesn’t that apply to just about everything?
  4. Do what you can to strengthen the muscles in your neck & throat. Just like PTs and OTs help us to strengthening the muscles in our body, SLPs help their patients to strengthen as well.

When we reach the ripe old age of 40, a bell goes off in our heads that says, “It’s time to take care of ourselves.”  Can you relate?  It can be done!  Feel free to contact us if you want to share your experience or have any questions.

Matt McGarvey is Vice President of Business Development at Language Fundamentals.  He is a graduate of Le Moyne College in Syracuse, NY and also earned an MBA in Health Systems Administration from Union Graduate College in Schenectady, NY.

Using FEES to Assess Aspiration in the Geriatric Population

 Treating dysphagia in the skilled nursing area requires a highly trained individual with a balance of medical expertise, compassion and an understanding of cultural norms.  The job can be incredibly demanding while at the same time as equally rewarding.  As a Speech Language Pathologist, I know that it is incredibly important to use every tool available to me to ensure I arrive at the appropriate diet and liquid consistency possible for the patient.

 We have been using Flexible Endoscopic Evaluation of the Swallow (FEES) for over 15 years in New York providing the Skilled Nursing Facilities we serve with onsite evaluations that enable myself and other clinicians the opportunity to literally see if a resident is tolerating his or her foods and fluids, if there are compensatory strategies that ensure safe toleration of a diet and, hopefully, rule out any evidence of silent aspiration.  When we first began, there were some legitimate questions and concerns raised by facility owners and administrators who need to see the value in performing these tests in their facilities. 

 Surprisingly, we still run across some facilities that need to see the value in FEES even as it has been generally accepted testing procedure throughout the industry.   Administrators and owners often need to be reminded that neurogenic dysphagia, one of the most frequent and prognostically relevant neurological deficits in a variety of disorders, such as stroke and Parkinsonism is often difficult to identify and measure without an objective study.  It allows evaluation of the efficacy and safety of swallowing, determination of appropriate feeding strategies and assessment of the efficacy of different swallowing maneuvers. The literature also indicates that FEES is a safe and well-tolerated procedure (Dziewas, et. al. 2016)

 FEES can be performed in the facility, at bedside or wherever the resident typically eats, and is performed with no exposure to radiation unlike a modified barium swallow study.   In addition, the test is reimbursable under Medicare Part B in a SNF on a UB-04 as well as most HMO providers.   

 Got questions about Speech Therapy, FEES testing, Skilled Nursing Facility Rehab, RCS-1 or maybe something else?  We’d love to help!   Message us in the space below!



Dziewas, R., Glahn, J., Helfer, C., Ickenstein, G., Keller, J., Ledl, C., … Busse, O. (2016). Flexible endoscopic evaluation of swallowing (FEES) for neurogenic dysphagia: training curriculum of the German Society of Neurology and the German stroke society. BMC Medical Education, 16, 70.



6 Habits to Help You Become a Better Clinician

Every once in a while, I like to take a moment and reflect about our profession as a whole and the work we perform with the gerontologic population specifically.   Good Speech Language Pathologists are an incredible mix of scientist, counselor and educator and like many professions it takes hard work and dedication to continue to stay at the top of our craft.  Through my years as a clinician, I have seen that the great clinicians, my heroes, have had certain habits in common that I have tried to emulate.  Below is a non-exhaustive list of what I believe are some of the most essential attributes each have had.

  1. Question everything you know (except your core values)

Often, we all, young and old clinicians alike, believe that the way that we were taught or the way we have been doing things is in fact the way that things have to be done.  One of the things I learned from a supervising clinician when I was in graduate school was that you can’t always change the behaviors of your client but you can always change your own.  Flexibility and willingness to explore new avenues is essential to changing and adapting to new clients and new environments.  While that is true for almost everything, there are the parts of your clinical self, your integrity, your compassion or your willingness to help that should always remain.

 2. Read something new every month

Each one of us is busy and reading journals, articles or even the ASHA listserv may feel an awful lot like homework at times.  Making a commitment to bump up the time you spend on staying up to date is a great way to make staying current a habit.  Taking 30 to 60 minutes a week or even a month to read something new within our profession allows us to see what new procedures, interventions or research is out there.  Reading research is not as easy as reading a novel.  We need to read articles with a skeptical eye and not take the word of literature as truth while at the same time not dismissing possible important new information because it is different.

 3. Experiment

Given, we are in an era of evidence-based practice ergo, everything we should be doing should have some evidence that it will lead to positive results, so I am not speaking of wearing onion halves as earmuffs to increase cognition.  Having said that I challenge each and every one of us to stretch beyond your current bag of tricks and try something new that you haven’t tried before.  Experimenting on the types of activities we perform, the pace of treatment or our interactions with our clients are all subjects of potential experimentation.

 4. Write down what you learn

You know that old expression, “if you didn’t document than you dint do it”?  Well that expression carries a bit of weight in life as well.  Writing or journaling is a great way to get a better understanding of how therapy sessions are going and the activities and procedures are working.  Journaling also chronicles your personal journey through your professional career and allows you the opportunity to look back and reflect on where you came from and see how you’ve changed as a clinician over the months and years.  Writing incorporates other parts of the brain that may help stimulate potential new insights.

 5. Stimulate your brain in areas away from speech

Having interests, hobbies and diversions outside speech pathology are more than a way to decompress after a day of work.  Gaining a proficiency in something other than speech stimulates your brain differently and allows for the possibility for each of us to gain a new perspective that we can bring back to the profession.

 6. Exercise, eat well, rest and repeat

I guess this may go without saying but exercise, diet and rest are essential for anyone to be their best.  Research shows that exercise increases blood flow to the brain, which increases oxygen levels.  This coupled with proper diet and rest allow our bodies to continue to perform as best as possible as we help others to make improvements.

RCS-1 is Coming. Why the Change?

For years we have been hearing from key policy makers in Washington D.C about the inequities associated with Medicare Reimbursement to Skilled Nursing Facilities.

The harshest critics of the SNF industry felt providers were giving excessive therapy minutes to drive reimbursement with little regard to diagnosis or clinical condition of the patient. The implementation of MDS 3.0 back in October 2010 eliminated reimbursement for concurrent therapy and an increased the focus on the delivery of individual therapy. (Yes, group therapy had a brief “cup of coffee” for one year, during FY 2011).

In August 2015, an article published in the Wall Street Journal called “How Medicare Rewards Nursing Homes for Delivering Copious Amounts of Therapy” sent shockwaves through the industry yet was based on a sample of just 500 claims! SNF providers were in turn outraged that an article about such a small sample overshadowed their hard work in returning healthy seniors back to the community.

With 92% of all Medicare Part A patients in a Rehab category under PPS, SNFs began to follow a rigid adherence to therapy minute planning, MDS schedules, look-back periods, etc. to meet RUG categories. Phrases like “hugging the RUG,” and “treating to the minutes” were born.

According to PEPPER reports released over the recent years, utilization of Ultra High therapy increased steadily (The 50th percentile nationally rose to over 67% in 2015 compared to around 47% in 2012).
SNF providers will point out, and rightfully so, that they have been seeing more medically complex patients with more co-morbidities than ever admitted to their facilities. Therefore, these patients require more therapy, not less, to show functional gains and have safe discharges back to the community.

Whether warranted or not, the increase in therapy utilization produced an audit culture around the country that called into question the “necessity” of therapy services. SNF Providers began to experience RAC audits, ZPIC audits, Probe Reviews and more all aimed at recouping reimbursement and denying claims thought to be “not medically necessary.”

In May 2017 the Advanced Notice of Proposed Rulemaking (CMS-1686) introduced the Resident Classification System (RCS-1) as a revision to the Medicare Part A reimbursement system and a replacement for the RUG IV System. In the RCS-1 System, the amount of therapy minutes is no longer a “driver” of per diem reimbursement.

In the upcoming weeks we will dive deeper into the highlights of RCS-1 and begin our preparations for an October 2018 implementation.