3 Reasons Why Speech Language Pathology is Such a Rewarding Profession

I graduated in August of 1997 with my master’s degree in communication disorders and was on my way to becoming a Speech Language Pathologist.  So, on this the 21st anniversary of my degree I realize my career is old enough to drink. 

 Helping Other People: Anniversaries are a great time to reflect, to go back and look at why.  Why speech pathology?  I think my reasons that brought me to speech pathology are similar to others in our profession, I wanted to help people.   I love the medical side of our profession working clinically to help people communicate as well as eat, chew and swallow has always been incredibly rewarding to me. 

 Following Your Passion: You rarely find someone who just “ends up” a speech therapist.  There is usually someone in a young clinician’s life that directs him or her in that direction.  They may have been in speech as a child or had an older relative that need speech in the hospital or SNF to improve function.  Not everyone knows what type of population (either early intervention, school age, adults or geriatric) they want to work with when they get to school.  It is one of the reasons why we are required to complete clinical practicums and work with real live people.  I think this initial catalyst is what separates great speech therapists, from other professions.  There is (or at least should be) a drive, a passion, towards the profession and those to whom we have promised to serve.  A force that pushes us to care for our patients, clients or students as best we can.  It pushes us to not settle for good enough when we know in our clinical hearts that there is more that we can do and more that they can do for themselves. 

Michael Webb, CEO of Language Fundamentals

 Life-Long Learning: For myself, I fell in love with speech during my first class, psycholinguistics.  Psycholinguistics is the development of language or the interrelation between linguistic factors and psychological aspects.  It was one of the most fascinating and well taught courses of my adult life.  The instructor, Mark Ylvisaker, PhD. became my mentor throughout college and beyond.  We learned about the brain, communication, morphology and syntax.  It felt like, for the first time, it was OK to embrace my inner nerd.  I will always remember that class fondly and Mark will always be in my heart. 

 I realized that I wanted to work in the medical setting when I had the opportunity to view my very first modified barium swallow test (MBS).  This is a video x-ray (fluoroscopy) of a person while they are swallowing.  It was my first real life experience of witnessing an actual person’s inside.  It was fantastic! 

Want to connect?  I’d love to be a resource!

Speech Therapy and Music Therapy: Teamwork Yields Successful Outcomes

During my 2017 Spring semester of grad school, I was a student clinician in the Nazareth College Neurogenic Communication and Cognition Clinic. This on campus clinic provides speech, language, and cognitive services to individuals with acquired disorders. While I gained experience working one-on-one with clients, I was also given the opportunity to engage in group therapy co-treatments with other disciplines including physical therapy, art therapy, occupational therapy, and music therapy where I gained additional appreciation for disciplines we often work closely with as Speech-Language Pathologists.

My speech therapy and music therapy co-treatment led to a unique experience working with an individual with Right Hemisphere Brain Damage (RHD). One of the main deficits presented in this client’s case was aprosodia, involving a breakdown in prosodic contours of speech. This affected the client’s linguistic and affective expressive and receptive prosody during conversational speech, with a marked rising pitch at the end of most utterances. Due to the limited evidence-based literature in the field regarding treatment approaches for aprosodia, my professor, Dr. Melissa Johnson, and I decided to conduct our own research throughout the semester focused on aprosodia secondary to RHD.

 Throughout the semester our speech and music therapy co-treatment components included:

  •  Vocal warm-ups
  • Unison or client-only singing of familiar songs with musical accompaniment
  • Cognitive-linguistic analysis of the prosodic features needed to convey emotion (happy, sad, angry) in semantically neutral sentences
  • Drumming exercises targeting rhythmic control
  • Oral reading exercises targeting production and self-monitoring of rate and prosody
  • Naturalistic conversation to promote generalization

 Our findings at the end of the semester between baseline data and post-treatment data showed an improvement in speech rhythm with significant improvement in affective and linguistic prosody. Dr. Johnson and I decided to send a research proposal to the American Speech-Language-Hearing Association to participate in a poster presentation at the 2017 ASHA Convention to share our findings; come Fall 2017, we were off to Los Angeles, California sharing our findings with other professionals from across the country.

Stephanie Cassel with Dr. Melissa Johnson

The experience I gained both personally and professionally from the co-treatments, the research process, and the poster presentation at ASHA made a huge impact on me as I began my clinical work; knowing that a meaningful and thoughtful treatment plan was successful for the client was also an added bonus! With the many opportunities I have been presented with, I am thankful, and as I now move forward through my Clinical Fellowship Year I hope to continue to make a difference in my patient’s lives while continuing to grow as a professional clinician.

About The Author:

Originally from Syracuse, NY Stephanie Casale has a Bachelors Degree from Nazareth College in Rochester, NY.  She is also a graduate of Nazareth’s Speech Language Pathology Program.  Stephanie is a Clinical Fellow with Language Fundamentals in Rochester, NY.  In her spare time she enjoys reading, spending time outdoors, and visiting family in her home town of Syracuse.

If you have any related thoughts or ideas, we’d love to hear


The Top 5 Things I’ve Learned About PDPM (So Far)

Skilled Nursing Facility Providers around the country are beginning to prepare for the Patient Driven Payment Model (PDPM) which is scheduled to be implemented on October 1, 2019. 

Anytime a new system is introduced, industry stakeholders face a learning curve to prepare for the implementation in hopes of coming out on top.  We at Language Fundamentals are no exception and recognize that we as an industry still have much to learn.

Here’s the Top 5 Things I’ve Learned about PDPM (so far):

 1.       Nursing should justify skilled care – This has always been best practice, but somewhere along the way, SNFs began relying too heavily on therapy.    Identifying the primary reason for stay and all medical complexities in our coding and documentation will be essential under PDPM.

 2.       Speech Therapy is now front and center – PDPM has shifted money to the new Speech Component which has the largest variation or “spread” in per diem reimbursement between the highest level of speech needs and the least ($92.81 vs. $15.06). Therefore, Speech must have a high level of competency in evaluating the patient, identifying speech related comorbidities and developing a plan of treatment. Those who devote the optimal resources to having versatile and proactive Speech Therapy Department should see a positive outcome 😊

Michael Webb, CEO of Language Fundamentals presenting to the GHFA in April 2018


 3.       ADL coding will be confusing- Functional Score will be derived from Section GG and will have different yet significant impacts on the PT / OT and Nursing components.  A higher score in GG will now mean more functional independence and will have an inverse effect on said PT / OT and nursing components.  In Case Mix states, section G will still be used to determine ADL score while still using the traditional scale. 

 4.       Efficiency in PT / OT will be their mission- Since the amount of therapy minutes will no longer be a driver of reimbursement, our colleagues in PT and OT are now tasked with obtaining the best outcomes with the maximum amount of efficiency.  Concurrent and Group Therapy could become useful tools once again.  Number of minutes delivered will still be tracked in MDS Section 0.  Could this be a potential audit area? 

 5.       Accuracy of Diagnosis Coding – Every ICD-10 code is linked to 1 of the 10 clinical categories.  It’s time to really hone our skills when it comes to coding and also engaging our physicians in the process.

There will certainly be a great deal of debate and discussion over the next year. We’d love to hear your thoughts and insight.


Sights and Sounds from “Peace Love and Reimbursement.”

Last week’s Zimmet Healthcare Services Group Annual Conference in Atlantic City was an thrilling experience. Over 1,200 people gathered at the Borgata Resort and Casino to learn and network as one of the most important industry changes is now looming just over one year away.

Since the FY 2019 CMS Final Rule has been finalized, it means the Patient Driven Payment Model (PDPM) is coming and SNF stakeholders must adapt. Attending my first ever Zimmet conference, I frequently found myself in the fascinating roles of spectator and listener. Here’s some of what I observed:

1. I think we all knew that the days of being reimbursed based on the delivery of therapy minutes were numbered. It was useful for a while, but its time to move on.

2. Years ago, I was taught that nursing was the foundation of Skilled Care. The industry got away from that, so we all need to get back to it.

3. Hospital based SNFs could be making a comeback. We will see.

4. Like any other change, PDPM represents an opportunity. It appears to be an opportunity to improve the delivery of patient care by really focusing on the clinical condition of the patient.

5. Different states seem to be shifting their methodology / approach when it comes to Case Mix. Is this in response to the perceived “gaming of the system” by providers??

6. “Speech is Boss!!” I heard that loud and clear. Speech Therapy Service will have an enhanced role under PDPM. All patients will need to be evaluated in time for the 5-day MDS. To quote Mike Sciacca, “Speech is Boss!” Thank you, Mike Sciacca!

7. Lots of great discussion about data and where it comes from. Keep a close eye on your source.

8. PDPM is 14 months away. Having been around the block once or twice, I wouldn’t just look at a numerical analysis of how your RUG scores would translate into PDPM. I recommend having a trained clinical eye get into the medical records of your current Medicare patients and seeing what they would look like under PDPM. Remember, the volume of therapy minutes will have zero impact on reimbursement under PDPM.
• Would there be a reimbursement difference?
• What would be the impact of changes in the Functional / ADL Score?
• Does the nursing documentation support skilled care?

Lots of exciting stuff.  We’d love to hear your thoughts in the comment box below.

Would you like to talk about how Language Fundamentals can provide the best Speech Therapy available to your SNF?  Let’s talk.

Why Speech Therapy and Dietary Need to be Besties

While working in a skilled nursing facility, Speech Language Pathologists need to present with great communication skills throughout the facility while modeling positive, professional dialogue with nurses, doctors, other therapists as well as the residents.  Working closely and collaboratively with the dietician is paramount to a proper speech program.   Why?  Because dieticians and diet techs bring SLPs valuable information on the residents’ food preferences, unexplained weight loss, lab changes, changes in eating habits, as well as a myriad of other information.

Through my years of working in SNFs, I have had the pleasure of working with some great dietary staff.  I have also had the eye-opening experience of what can happen when relationships between dietary and SLPs are less than positive.  Below are some of the important factors that demonstrate the need and effectiveness of great collaboration:


              As stated above, dietary is typically one of the first to receive information on weight changes including significant unexplained weight loss.  In most of these cases speech should be involved to assess if there are any swallowing/dysphagia concerns that contributed to the weight loss.  Often, speech can play a pivotal role in maintaining and even increasing weight, when appropriate, by increasing muscle strength and endurance.  Teaching compensatory strategies that allow for increased caloric intake and simply give the resident confidence to eat safely and functionally.

Diet Upgrades

Evaluating a resident for a diet upgrade and bringing that resident back to their prior level of function is a favorite task of mine.  Dietary staff meet with each resident on a regular basis to discuss likes, dislikes and ways to improve the dining experience.  When dietary finds out that a resident would really love to be upgraded and lets the SLP know, he or she then can review and assess the resident for safety.  Trial trays and foods allow the clinician to assess the resident for safety, strength and ability to tolerate foods and fluids of a more natural consistency thereby getting them ready to tolerate an upgraded diet.  This is an area for a qualified clinician.

When walking into a building that has been without proper speech, we have seen dietary trying to tackle this on their own, which scary at the best of times and risky not only to the resident but to the facility as well.


Clear lines of communication include clear documentation in the medical record.  Acknowledgment and documentation of problem areas and treatment by other professions helps tell the story in the medical record.  It demonstrates that the facility has identified an area of concern and has taken steps to address it.  Congruent documentation from dietary and speech (and nursing too!) help describe the quality of care each facility should try to achieve.

Want to share your thoughts?  I’d love to hear.

What Would Regulatory Relief Mean for SNFs?

At the recent NYSHFA Annual Convention, there was a great deal of discussion around the topic of Regulatory Relief.  For an industry that could be the most over-regulated industry in the history of over-regulated industries, that sounds great.  So, what does it mean?

Mark Parkinson, President and CEO of the American Health Care Association (AHCA) recently appeared before the House Ways and Means Committee to advocate for legislation to reduce the enormous amount of regulations that envelop the Post-Acute Care industry.

I’ve always been one of those people that likes to know where I (or we) stand.  I have assembled below a short list of the most recent regulatory related issues in Post-Acute care, some of which are good things.  In the coming weeks, we can expand on this list. I’d love to hear your input.

Here goes:

1.       Updates to the Survey Process – The most significant aspect has been incorporating the new F-tags, facility assessments and other elements of the Requirements of Participation

2.       Requirements of Participation – Phase 3 will go into effect November 2019. Lots of staff training to be performed prior to then

3.       Five-Star Rating System & Value Based Purchasing – SNFs who are below 3 stars or less could be left out of provider networks.  With so much emphasis on the Survey Star (see #1), there is a lot of pressure to have great surveys 

4.       Reducing Readmissions – Facilities low readmission rates will avoid potential reimbursement cuts

5.       Potential statutes requiring staff to patient ratios – This would be disastrous with everyone seemingly having staffing needs

6.       Lifting federal restrictions on CNA training – this would be awesome!

7.       Patients over Paperwork initiative – Also awesome!!

8.       Combating Opioid Epidemic – An issue that has come out of nowhere

9.       Patient Driven Payment Model (PDPM) Implementation to replace the RUG-IV System in October 2019 – will significantly changed how Rehab is delivered and how Medicare patients are treated

This is just the “off the top of my head” list that doesn’t include the constant battles of:

1.       Driving Census

2.       Case mix

3.       Staffing / staff morale

4.       Improving reimbursement & compliance

5.       Maintaining and improving Quality Measures

What’s missing from the list is what I will call “Getting Ahead.”  Initiatives around EMR investment and winning AHCA Silver & Gold Quality Awards are out of reach for all but a handful because of resource constraints and slim margins.

Is it time for Regulatory Relief?  I’d say so.  Where do we begin?

4 Great Reasons to Outsource the Speech Therapy Department at your SNF

Skilled Nursing Facilities across the country are facing a multitude of unique challenges from that of any other industry.  I could list them all, but that would probably cover more than an entire article.   Administrators and Operators are being challenged to “do more with less” to run a business where top line revenue is highly dependent on patient volume and payor mix. Already razor thin margins are impacted by survey issues, Medicaid shortfalls, and a multitude of State and Federal regulations are pushing many buildings to the brink.

Meanwhile, most Nursing Home Administrators will place staffing issues & turnover somewhere in their Top 3 biggest headaches.

Savvy operators will look at which departments could potentially be outsourced to provide maximum return on investment while reducing operating expenses.    The departments are most often outsourced are:

  • Housekeeping & Laundry
  • Dietary
  • Rehabilitation

Outsourcing the entire rehabilitation department is a big operational decision.  At many buildings, it can be a great decision by choosing the right rehab partner for your organization and culture.  Other times, it isn’t the right fit.  Amongst the many factors that go into this decision include, staffing, payor mix, volume, geography, leadership, culture, training, expertise and more.

Have you ever drilled down on the advantages of outsourcing just Speech Therapy?

Sometimes, a great Administrator will say to me “I already have 2 speech therapists, so I am all set.”  Well, let’s hold the phone right there and dig into the ways to make a functioning speech department into a great one.

Finding the Right Speech Therapist – Let’s face it Speech Therapists aren’t easy to find, and not all of them want to work with a post-acute care population.  In order to excel in today’s SNF, your Speech Therapist must excel at treating dysphagia, speech language deficits, and cognitive impairment.  If not, you might be missing opportunities to improves patient care and capture reimbursement.

Providing Education and Oversight – PT, OT and Speech come from different backgrounds and bring different perspective. Buildings typically have multiple PTs and OTs in the building to be a resource to one another and also develop programs. Often, Speech is flying solo and have few resources available to talk about challenging cases or get the billing & regulatory updates needed. Having the “lifeline” they need will help them case manage and improve overall patient care.   Also, having their documentation reviewed by another Speech Therapist will help to ensure that documentation supports billing, especially when dealing with multiple payors (Medicare, Medicare Advantage, Medicaid, etc.)

Productivity – Yes, the dreaded “P” word. How do you measure productivity for Speech?  Its different than for PT / OT.  The average case load for a Speech Therapist should be around 12-15.  If its less, you might have an efficiency issue.  If its more, consider looking into what services might be missing.  We’d love to be a resource if you have questions.

Backup and Coverage – Isn’t it difficult when you are without Speech Therapy because its time for vacation?  Sometimes a couple hours of per diem help doesn’t cut it when that per diem Speech Therapist doesn’t know your building or has minimal experience with medical speech pathology.   A seamless system of backup and coverage needs to be in place to maintain caseload.

If you have any thoughts, ideas or questions, I’d love to hear from you!

4 Ways Speech Therapy Can Impact Your Case Mix Index

The following represents an outline of the four overarching themes that Speech Therapy should regularly examine for each resident, especially during Case Mix window.


I often joke about who our best friends are in the facility.  It is usually a “three-way tie” between nursing, dietary and MDS.   Let’s just say it is the MDS coordinator.  The MDS coordinator has key information on the upcoming Assessment Reference Date (and corresponding look back period) for resident’s annual or quarterly MDS.  This information is crucial to us as speech language pathologists because it allows us the opportunity to assess the resident’s current plan of care.  This information needs to be disseminated with enough time to assess the resident and implement a plan of treatment.


The MDS is a time for the entire team to review a resident’s care plan.  The SLP should be focusing on the following areas:

  1. Is the resident on the correct diet? This means least restrictive while reducing the risk of aspiration and choking.
  2. Does the resident have adequate supervision to reduce that risk of aspiration and choking? Speech should look at pacing and safety awareness abilities.
  3. Is the resident able communicate for purposes of medical needs and wants.
  4. Is the resident experiencing any cognitive decline and becoming unable to understand the medical plans implemented?

Looking at the Entire Person:

Speech often looks at the person “from the neck up” however let’s make certain the rest of the person is being assessed as well.  While we are assessing swallow function, it is up to occupational therapy to assess if the resident can bring food and fluids from the table to their mouth in a functional manner.  Physical therapy also tests the patient’s mobility.  We are a collective team, each bringing its own unique perspective, to give support to the resident.

Looking at residents that are NPO:

One area we find overlooked in skilled nursing is the re-assessment of residents who are currently not eating by mouth (NPO).  We often find when we walk into a new facility that residents have been diagnosed with a severe dysphagia placed on a PEG tube for nutrition and hydration and then stay that way indefinitely.  There are several reasons to continuously look at these residents.  First, we want to assess if there has been any spontaneous recover, are they more awake, alert able to follow directions etc.  Secondly, there may be new procedures, treatments or strategies that were unavailable prior.  Lastly, it’s the right thing to do, as these people are under our care we have a responsibility to assess individuals’ who are NPO to provide appropriate care.

By doing these 4 things on a consistent basis, I think you’ll see the significant impact Speech Therapy can have on your long-term care population and on your building’s Case Mix Index.  If you have any questions or would like to talk, I’d love to hear from you.


11 Myths about Dyspagia — Part Two

In a recent post, we examined 5 common myths about dysphagia.  In this edition, we will introduce myths 6 through 11.

MYTH 6: Runny nose is an indication of aspiration: Interestingly, some of the geriatric population we work with might present with a runny nose, ESPECIALLY when eating and not otherwise. It used to be considered an indicator of dysphagia; however it is often a condition called gustatory rhinitis which results in this symptom and apparently has nothing to do with swallow mechanism.

MYTH 7: Coughing = Aspiration/penetration: A person can cough or throat clear due to multiple reasons including Laryngopharyngeal reflux (LPR) and not just aspiration/penetration.  A trained clinician need to perform a comprehensive examination to assess the presence or absence of dysphagia.

MYTH 8: Straws cause aspiration  A straw is a definite NO for most people having difficulty swallowing liquids: Recommendation of straws is patient based. I personally have had lot of patients with dementia who do better with straw due to the sucking reflex improving the swallowing.

MYTH 9: It’s not Right Lower Lobe (RLL) pneumonia, so he/she probably did not aspirate: Pneumonia developed due to aspiration does not always present in the RLL. The location of infiltrate does not have to be on the right side all the time. Right is more prone because of its anatomical structure, however infiltration may also be influenced by a persons position. Distribution of aspiration depends upon the positioning of the patient during the event.

MYTH 10: Tube feeding prevents aspiration: Often times people assume that if an individual in no longer eating (NPO) and they are on a tube feeding for nutrition and hydration that that person is no longer at risk of aspiration.  In fact, tube feedings do not necessarily reduce a patient’s risk for aspiration.  Tube feedings can be refluxed and then aspirated.

MYTH 11: Objective evaluations are used to determine only the presence or absence of aspiration:  Objective evaluations give much more valuable information than just letting us know the presence or absence of aspiration/penetration. It lets us know the pathophysiology which in turn helps us to develop customized goals to restore swallow function.  We can assess different consistencies, posture modifications and other compensatory strategies to identify the most appropriate diet and the future course of therapy.

Thanks for reading.  I hope you enjoyed and would love to hear your thoughts.

About the Author:

Ranjini Rajan, CCC-SLP is a Speech Language Pathologist with Language Fundamentals.  Ranjini is originally from India and is a graduate of the All India Institute of Speech and Hearing.  She is passionate about bi/multilingualism, cognition, language and adult speech and language disorders.


5 Big Changes That Will Determine Winners AND Losers Under the Patient Driven Payment Model

Last week at the Leading Age of New York Annual Convention in Saratoga Springs, NY, we were able to attend an excellent presentation performed by Zimmet Healthcare Services Group on the new Patient Driven Payment Model (PDPM) slated for an October 1, 2019 implementation.

The Patient Driven Payment Model System has been proposed to replace the RUG-IV System for Medicare Part A reimbursement to Skilled Nursing Facilities and is an updated version to the RCS-1 system introduced last Spring.

The PDPM System is being touted as “budget neutral” even the CMS Proposed Rule calls for a large infusion of capital ($850M) into the system.  Whenever any type of change is introduced as “budget neutral,” that means by definition there must be winners and losers.

If the Patient Driven Payment Model does go into effect, we will see the most significant change in the world of Medicare reimbursement since MDS 3.0 in 2010.  The highlights will include:

 1.       A streamlined MDS Schedule with fewer required assessments.

2.       Section GG will be used to record ADLs and will utilize a different scoring mechanism than Section G.

3.       Speech Therapy will have its own category, and the skill set of the Speech Language Pathologists will now play a greater  role, especially in assessing new SNF admissions.

4.       Reimbursement will be driven by patient characteristics and co-morbidities, instead of the number of therapy minutes delivered.

5.       The number of therapy minutes delivered will still be tracked, placing a premium on efficiency and outcomes. RCS-1 left the minute tracking requirement in doubt, and PDPM has clarified.

 One thing is for certain, critics of the SNF industry have been outspoken against a system in which the delivery of therapy minutes is a key driver of reimbursement.  Experts feel the PDPM system has certainly removed that from the equation.

With the public comment period to CMS open until June 26, 2018, sharing the thoughts of industry stakeholders, providers especially, is encouraged.

 We’d love to hear your thoughts.