Outpatient Medical Setting

By: Julian Garcia IV, MS, CCC-SLP, DHR Health Therapy Institute

An outpatient medical setting functions very similarly to a traditional doctor’s office. One can expect to work with a diverse staff of individuals filling different roles and all working together to help the clinic function smoothly. There will be front office staff to handle arrivals, scheduling, and billing. Patient representatives and insurance verifiers will work hard to make sure patients have a smooth experience in the outpatient setting. A therapy team will consist of technicians, assistants, and therapists from each therapeutic discipline to carry out patient care. Overseeing the whole operation will be a clinical supervisor or director.

Outpatient speech-language pathologist (SLP) staff size will be related to the size of the clinic and its affiliations. The SLP team may be comprised of full-time, part-time, and as needed (PRN) staff (guidelines of these statures are defined by the facility).

Caseloads will vary in relation to size and location of the facility. Referrals can come from local, regional, or out-of-state physicians. Once a referral is received, initial evaluations are scheduled and completed in a timely manner. A plan of care is then established by the evaluating SLP. Patients are initially treated one to five times a week for 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 will be re-evaluated. New recommendations are made and must be approved by the referring physician in order to continue services. When working in an outpatient medical setting, your daily schedule will involve the evaluation of new patients, re-evaluation of current patients, and conduction of treatment sessions. Allotted time for evaluations varies from 30 to 90 minutes, and typical treatment times range from 30 to 60 minutes a session. Other daily duties will include documentation, conferencing with physicians, family counseling, meetings, and multi-disciplinary collaborations.

Procedures often performed by the SLP in an outpatient medical setting:

  • Speech-language-cognition evaluations
  • Clinical swallow evaluations
  • Voice evaluations/stroboscopy
  • Fiber optic evaluation of swallowing (FEES)
  • Speech-language therapy
  • Cognitive therapy
  • Dysphagia therapy
  • Voice therapy
  • Counseling pre-/post-total laryngectomy
  • Voice restoration (electro-larynx, TEP)
  • Augmentative and alternative communication (AAC) trials and training

Patients often seen in an outpatient medical setting:

  • Non-traumatic brain injuries (CVA, tumors, infections)
  • Traumatic brain injuries (motor vehicle accidents [MVA], assaults, falls)
  • Post-op head and neck surgery (cancer, total laryngectomy)
  • Voice cases (PVFM, vocal fold paralysis, muscle tension dysphonia, etc.)
  • Advanced disorders and end-of-life care (dementia, Parkinson’s, MS, etc.)

Additional resources for SLPs getting started in outpatient care can be found here: https://www.asha.org/slp/healthcare/outpatient/.

Acute Care Medical Setting

By: Ashley Logan, MS, CCC-SLP, BCS-S, CLT, San Antonio Military Medical Center

Hospitals can range in size from a small rural hospital with potentially fewer than 10 beds to large-scale trauma centers with greater than 500 beds. The patient population ranges from birth through age 99+, although some hospitals have separate pediatric and adult therapists who split up the inpatients by age (birth through 18 and 18 through 99+). Many hospitals have critical care (ICU) floors, transition units, and/or step-down medical floors where patients require less monitoring from both staff and machines. Speech-language pathologists (SLPs) are active at all levels of care and can even complete evaluations in the emergency department depending on policies at the individual hospital. Evaluations often occur at the bedside with whatever materials can be carried in by the SLP (and cleaned prior to next patient use), with the exception of videofluoroscopic swallow studies (VFSS), which are done in radiology.

Caseloads can range from as few as one to two patients in smaller hospitals to caseloads of greater than 30 to 40 in larger hospitals. SLPs are not expected to see all 30 to 40 patients per day; rather we tend to see patients in the order of acute need: new consults, patients due for repeat evaluations, therapy, etc. Staffing at hospitals in the SLP department can have varying ranges to match patient need, and often the SLP in the acute care setting has to ensure he/she is educating staff regarding the medical benefits of SLP consultation in the acute setting to ensure consults are being appropriately entered for patients who may have a speech-language, cognition, voice, airway, or swallowing need. Given the high demand and fast-paced nature of acute care, hospitals require SLPs to be proficient in all areas of service delivery. These clinicians need to be able to work quickly and independently to deliver medically necessary information ahead of patient discharge.

Patients who require post-acute care stays in rehabilitation facilities often stay in the hospital for a minimum of three days. Those with more critical injuries and/or placement challenges may stay much longer, with some patients staying a number of months in the hospital prior to discharge. In these instances, patients may complete the entire course of therapy with an SLP prior to ever leaving acute care. Given the multiple levels of medical acuity within the hospital, some patients may already have been in the hospital weeks to months prior to becoming appropriate for SLP evaluation and intervention. There is a wide range of patient presentations and post-evaluation needs across the age ranges and diagnoses.

Procedures often performed by the SLP in the hospital setting:

  • Clinical swallow evaluations
  • Fiber optic evaluation of swallowing (FEES)
  • VFSS evaluations
  • Speech-language-cognition evaluations
  • Trach and vent care, speaking valve (PMV) evaluations
  • Speech-language-cognitive-swallow therapy
  • Voice-related evaluations and therapy are often deferred to outpatient; however, if poor glottic closure is contributing to aspiration, glottic closure activities involving voicing may be initiated while still in the hospital as a part of swallow intervention.

Patients often seen in acute care:

  • Traumas (motor vehicle accidents, various other traumatic injuries)
  • Post-operative head and neck surgeries (cancer, anterior cervical discectomy and fusion [ACDF] spinal procedures)
  • Prolonged intubations (greater than 48 hours)
  • Chronic obstructive pulmonary disease (COPD) exacerbations
  • Aspiration pneumonia
  • Traumatic brain injuries
  • Advanced disorders and end-of-life care (dementia, Parkinson’s, ALS, MS, etc.)

Additional resources for SLPs getting started in acute care can be found here: https://www.asha.org/slp/healthcare/start_acute_care/.