June 2011 Newsletter
Summer is here!
Happy Father’s Day!
Do not forget to fly your American flag on the 14th in honor of our country, our troops and our freedom!
Clinical Café Newsletter
By: Ronda Polansky M.S. CCC-SLP
Many times the difference between success and failure is doing something nearly right and doing something exactly right!
DiagnosTEX website – The Clinical Café is a reference source for you. All previous handouts and newsletters can be found there. You can type a topic into the search section and it will locate all newsletters and handouts with that key word. All upcoming conferences will also be listed on the calendar. www.dysphagiadiagnostex.com
ESTIM course in Arlington in May – Great turnout and great attendees!!!!! We had a full house! Thank you Rehab Synergies for hosting, it was a great location and a great lunch!
Scheduling pending studies with specific time and day requests, I know I sound so repetitive on this topic, but I feel like I need to reiterate as we get many calls when we can not be prompt on scheduling patients with restrictions on days and times. Mobile is for the convenience of us coming to you not the flexibility of a specific time and day. If the patient can only be seen on a Tuesday or Thursday, or a certain time of day, that may delay scheduling for up to a week at a time. Due to gas prices and efficiency of scheduling to meet the max number of pending requests we schedule based on geographical area. Our mobile unit is not a STAT service. If you need an MBSS more promptly or need it on a specific day or time or multiple days notice you may need to consider sending the patient out to a free standing our patient facility that can be more accommodating to specific days and times. Based on the way we schedule our multiple vans, we are able to provide you with a days notice for scheduling, but no further out than that
DiagnosTEX can not guarantee nor consistently meet all time requests or work around all personal local SLP schedules and facility coverage locations, over-time staff issues, facility department meetings, patient group treatments, Dr appt’s, birthday parties, families work schedules, patient dialysis schedules, morning or afternoon only requests, nursing staff limitations at shift change, scheduled meal times, medication administration, availability of a chair, scheduled therapy times of an outpatient, etc, etc., etc. We complete over 700 studies a month in the DFW area and there is absolutely no way to meet all of these requests with the number of facilities, patients, and SLP’s we service, or we could not operate and be as efficient as we are in meeting those patients needs that have no limitations set by them or the facility staff.Mobileis and always will be subject to travel delays, as this is the nature of the mobile business. We encounter traffic, construction, bad weather days, add-ons, difficult patients and involved families, patients not being up and ready when we arrive (waiting an extra 15 min on 4 of these in a day can put us an hour behind for the day!) When we schedule, this is truly an estimated time of arrival (ETA), certainly not a guarantee. Being on time not only benefits you but us as well! Our staff will always call on their way, so please provide us with a solid contact number to reach you as we head your direction.
We love providing you with convenience of mobile MBSS and we work very hard at being on time and being as efficient as possible, but sometimes no matter how hard we work for it, we can encounter obstacles that are out of our control. Mobiledefinitely requires flexibility during the day to all involved, including us!
Is your patient appropriate for Strategies??? Is the pt. appropriate for strategies? This question appears on our history intake form. Treatment strategies should be introduced during the videofluoroscopic evaluation to determine the effectiveness of the strategy prior to implementation. Several categories of interventions exist including postural changes, sensory procedures, maneuvers, diet changes, physiologic exercise, and orofacial prosthetics. Used alone or in combination, these options can be extremely successful in affording a patient safe and efficient oral intake. Cognition, memory, and cooperation are just a few factors which will impact safe and effective follow through of such strategies. This is so important in a recommendation. If any of these areas are questionable and could impact follow through, the patient may not be appropriate. The use of a strategy is used to protect the patient’s airway during PO. We should NOT consider the person “appropriate” for strategies with a diet recommendation if the response to the question “Is the patient appropriate for strategies?” is answered with any one of the following:
1) “questionable” 2) “50/50” 3) “sometimes” 4) “maybe” 5) “not sure”
Truly defined safety in PO must occur with 100% use of the strategy! Implementing a strategy only 50% of the time can not be considered effective for meals when you are placing an aspiration risk the other 50% of the time. Please evaluate your patient and carefully consider whether a strategy could be fully implemented and used effectively for a diet recommendation during an entire meal (for all 3 meals per day and during snacks). This will help us during the MBSS and reduce the risk of dysphagia once the recommendation is made for a PO diet.
MBSS Hall of Fame – Yes it happened! AND don’t ask us how!
Consult request forms are very important for our documentation –Please complete all of the blanks on this form as it is important for us know what diet the patient is on, a diagnosis related to possible dysphagia, dentition and pulmonary status, and signs and symptoms of dysphagia. Since you know these patients better than us, it is very helpful to us if you can provide this information before we get there so we are prepared and ready to evaluate. Thank you!
Home Health Service Contracts – The consolidated billing legislation states under PPS that a Home Health Agency (HHA) must bill for all Home Health services (which includes nursing and therapy services). DiagnosTEX provides mobile dysphagia consultation including the modified barium swallow study (MBSS) service. Included in this service is the speech therapy code 92611, which is the speech portion of the radiological examination for dysphagia (the MBSS). DiagnosTEX is unable to bill this code to Medicare because it falls under consolidated billing relating to speech therapy services. The HHA is responsible for reimbursing the provider of this service. The HH would then bill its fiscal intermediary and be reimbursed under the Medicare fee schedule. The law requires that all Home Health services paid on a cost basis be included in the PPS rate. Therefore, the PPS rate will include all nursing and therapy services. DiagnosTEX requires a signed service agreement with all entities to which we provide this service. This service agreement states the fee schedule for the 92611. If you have any questions, feel free to call and speak with our billing department. To continue servicing your Home Health residents, DiagnosTEX will require a signed service contract with the HHA and the 92611 will be billed to the HHA for the requested service. If we do not have a contract with the HHA, we will be unable to complete the requested service for the MBSS.
Interesting research touched on in the ASHA leader on “Hyoid Displacement and Cancer Treatment for Head and Neck”.
A new study emphasizes the importance of hyoid displacement in treatment and planning for patients who have received treatment for head and neck cancer. Researchers measured hyoid displacement in healthy persons with a normal swallow, post rad only, and post surgery only.
Radiation therapy patients had greater hyoid displacement than surgery patients. Bolus viscosity and measurement method significantly influenced displaced results: bolus, volume did not.
Journal of Speech, Language, and Hearing Research (doi: 10.1044/1092-4388(2010/10-0077)
Dysphagia Tidbit – Taste stimulation instead of PO trials
Taste and corresponding neuroanatomical level
- Taste (juice) – upper brain stem
- Taste (sweet and sour) – upper brain stem and possibly thalamus
- Bilateral massage to the masseter – motor cortex
- Spoon (room temp) – medulla, pre and post central gyrus for sensory and motor programming.
- Spoon (cold) – medulla, pre and post central gyrus for sensory and motor programming.
Assessing taste does not involve providing an actual bolus to the patient, but can be used to the give the clinician important baseline information regarding pre-swallowing and swallowing abilities, cognitive functioning and level of consciousness. Taste stimulation, rather than therapeutic trails or oral feeding, has been advocated for patients functioning and at minimal conscious state. Taste assessment can be an important first step in evaluating. Safety inPOfeedings with strong bite reflex or increased lethargy is a concern and these obstacles may also limit the ability to complete and MBSS or FEES.