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(Sorry for the long delay in posting.  My landlady’s internet has decided to play a long, tortuous game of “I’m working!  Just kidding!  No I’m not!” all week.   So I actually went in with her to work today because I have various things to get done  [read:  job applications] including the other half of this post, which I started almost a week ago.  In any case, hopefully I’ll have the internet back by Tuesday after the tech people come out Monday and return to making posts more regularly.  Again, sorry!)

So, in my last post I mentioned that I felt even going through four semesters of grad school before doing my internship, I didn’t really get the difference between in patient and out patient in a hospital.  It’s all a hospital, right?  It’s all speech therapy, right?  Look, I can’t think about that now because I’m just trying to survive this semester, okay??? ;)

In Patient

My description of in patient may be more extensive than out patient since I have personally experience more of the in patient side of things rather than the out patient side of things.  In patient is pretty much how I described the general outline of my day.  You start your morning by looking for new consults (requests for speech therapy put in by doctors–in the in patient setting this means SWALLOWING 80% of the time).  You then take all the new consults you have and go see them, by which I mean evaluate them.  As I mentioned in another post, this makes your schedule pretty flexible.  If you have multiple consults at a time, you can go see them in any order you wish.  Generally,  SLPs like to take care of the swallowing evals first, because, well, it’s eating.  Doctors, nurses, and the patients themselves, all like to know if s/he can eat or not.

After after the initial evaluation, you need to continue following them until they are discharged from speech or from the hospital altogether. For example, once we do a bedside swallow and determine a safe diet for a patient, we usually follow-up in the next day or two to make sure they are not coughing and choking on the diet we recommended.  If everything is okay (and they are medically stable and/or not likely to make any progress that would change his/her swallow) we would discharge them from speech.  In in patient, though, the patients are rapidly changing (hopefully for the better!).  When you see the patient, it is less evaluation and treatment and more evaluation and then re-evaluation and then more re-evaluation.  In in patient, hospital staff are trying to get the patient well enough to discharge; this is not the setting for long-term goals.  This also means that your caseload has a high turnover rate, unless there is a particularly medically complicated/fragile patient on your caseload.  By Friday, you may not have a single patient on your caseload that you had on Monday.

I love the flexibility this schedule allows (I get to write my SOAP notes right after I see a patient!  Although, if waiting until you’ve seen a few patients is your thing, that’s also do-able on this type of schedule!)  There’s also no danger of getting bored/tired of one patient.  It’s always changing!  It’s also awesome if you really like the evaluation side of thing and are less enamored to the treatment side.  (I mean, treatment does occur, but it is usually more constant re-evaluation.)  If you like solving puzzles and then moving on to the next one without really finding out the rest of the story, then in patient is for you.

Out Patient

Out patient pretty much is what you do at your graduate clinic.  People are scheduled for (usually) hour-long sessions at a time, and it is not uncommon to have 3 or 4 sessions back to back without a break to write a note.  The number of times you see people usually seems to vary with the type of therapy you provide.  T with her language and cognitive stuff tends to see people once every other week for an hour.  M on the other hand, who does a lot of voice, tends to see people more frequently; every day if she’s doing Lee Silverman Voice Treatment (LSVT).  Again, this is probably somewhat affected by M and T’s job description.  M is out patient therapy only, while T has out patients on Tuesday/Thursday, and does in patient the rest of the time.  (CI actually has out patients Monday/Wednesday and does in patient the rest of the time, but he tends to have fewer out patients overall.)

From the week I spent with T, out patient is a very different pace.  When doing in patient, things are flexible and you’re running around everywhere to your various clients.  Out patient has scheduled times, is less flexible, and doesn’t give you time to write notes in between.  (For me, this is the biggest negative.  Not that I’m not used to taking notes about a session and writing up a SOAP note the next day, or even later in the day, because that happened a lot in grad school, but I do personally prefer having the option to write out the note right after you finish with someone.)  The notes also tend to be longer in out patient, probably because you’re spending a whole hour with them working on goals instead of 30 minutes doing an evaluation.  Out patient gives you the opportunity to see your patient’s progress long term (insurance willing), which is definitely not something you see in in patient.  I really like that aspect of out patient.  It’s nice to help people meet goals and have some effective change in their life (well, besides changing their diet or giving them swallow strategies).

Basically, I think if you like a more structured environment and love seeing long-term outcomes with clients, out patient might be more interesting for you.  As of right now, I find both interesting for different reasons.  I think I lean a little more towards in patient right now for all the flexibility and moving about, but I know I’m less likely to be able to do the cognitive-linguistic stuff I love in the in patient setting.  Maybe I should look for a job that gives me the in patient/out patient mix like CI and T have.

If anyone has specific questions or wants clarifications about one setting versus the other, feel free to leave a comment and I’ll do my best to answer (with the caveat stated above that I’m not likely to get back to you until Tuesday at the earliest.  Damn internet.)!

It has been ridiculously busy these past few days…but I’m having a blast!  I’m assisting in bedside swallow evaluations, oral mech exams, and even the modified barium swallows.  Where to start?  I guess I’ll start with a general outline of my day, or basically the logistics of what me and my CI do.

General disclaimer:  different SLPs have different caseloads depending on the setting and/or mix of settings they work in.  Your mileage may vary.  This is how my day goes.

The day begins in the Tiny Office of SLP Awesomeness.  My CI does both inpatient and outpatient settings, although most of it is inpatient.  (By inpatient, I’m referring to people who are already admitted to the hospital for some other reason, e.g. stroke.  By outpatient I mean people who come into the clinic via referrals from another doctor.)  If CI has any outpatients scheduled, the appointment times are noted on the schedule.  So far it has not been more than 2 in a day.  Otherwise, my CI seems to have about 5-7 inpatients that he is currently following in the hospital.  We then check and see if there have been any more referrals for evaluations since we last checked yesterday.  Today their were two, but this varies.  We’ve not had a lot of referrals the past couple days, which sucks for me hour-wise, but I realize this means other peoples’ lives are not being affected in a dramatic way.

After that, we work our way through the inpatient list in any order we want to, working around any outpatients we have scheduled.  My CI likes to get the referrals done first thing, which I think is a good idea.  For a lot of these people it’s a matter of whether or not they are going to be eating, and doctors and nurses need to know as soon as possible.  Otherwise the schedule is completely flexible.  I really like this aspect.  It gives one a nice feeling of control over the situation (haha).  In between patients, my CI does the SOAP notes.  This varies from SLP to SLP as I’ve heard in the office.  Some do them immediately (my CI) while others wait until they have a few or more.  This is partly dependent on schedule and is, I think, more easily achieved with inpatient clients.  Since outpatient is all scheduled, you might have one client right after another with hardly a chance to write the SOAP note.  I like writing them right after because everything is still fresh in your mind (and as a student this is incredibly helpful.  I’m just beginning to juggle/remember each of the patients and their issues currently on the caseload.)

The day ends when there are no more patients to see on your caseload.  Pretty cool, huh?  I’m enjoying it so far.  Still having FAIL moments (I mean, I distinctly went against the processing going on in my brain and said flaccid dysarthria was an UPPER motor neuron problem, instead of a LOWER motor neuron problem. Stupid.  I ran into a door.  Gave a bad oral mech.)  Still having WIN moments (I’m remember a lot more from my swallowing and trach classes than I thought.  I have a pager!)  Still trying to be assertive and not so stupidly nervous that I can’t think straight (see also:  my classification of flaccid dysarthria).

That’s all I’ll cover for today, although I feel like I have enough topics for a week’s worth of posts.  Anyone have any preferences about what I write about next?  Bedside swallow evals?  Modified barium studies?  Trialing Passey-Muir speaking valves on trach patients?  Giving a bad oral mech?  (I swear I will nail the next one.  It was like I hadn’t done one before, which I have.)  Feel free to leave a comment if there is one you really want to hear about next and I’ll write it up in the next few days.

So a few days ago I mentioned there was a district-wide meeting of SLPs that I attended.  Is was quite interesting as they covered several topics, which I will briefly and not-so-briefly go over, depending on the topic.

One of the things discussed, was everyone’s caseload and how schools and schedules could be re-worked so that everyone had a manageable caseload.  It hadn’t occurred to me that the SLPs themselves could change around who is at what school and when, although it makes perfect sense seeing as they are actually the ones on the frontlines, so to speak, and know where help is needed.  Of course, it still has to go through the director, but it was good to see all of them working together to try and help a fellow SLP out to get to a manageable caseload.

There was also some discussion about ways to better use the current IEP program to write goals that accurately reflect what the SLPs are actually working on, while aligning with state standards.  (Trust me, these things were not written for SLPs.)  They didn’t come to a final decision, but all agreed that each person needs to do what works best for them individually anyway.

There was also some discussion about response to intervention (RtI) and how SLPs fit into the whole RtI model.  This is tricky and very much depends on the school and the individuals that make up that school.  For my part, I would say what the SLPs role in RtI at her/his school depends on what s/he wants that role to be.  For some SLPs, they may just have to carefully define the role they can play so that they are not stepping on others’ (e.g. reading specialists, learning disabled teachers) toes.  In others, they may have to advocate for an RtI model period.  (And of course, that would depend on your own feelings about RtI.)  RtI is only just beginning to be implemented across this school district, and so the SLPs agreed to give it more time and perhaps bring an RtI specialist to speak with them so they better understand the goals of RtI.

However, the majority of the time was spent discussing whether or not to implement and 3:1 model of service.  I had personally never heard of this prior to this day (although, it actually dovetails with the tenants of RtI).  Also, it was apparently piloted in my undergraduate city, Portland, Oregon, so I was even more surprised not to have heard of it.  It is endorsed by ASHA and there are quite a few discussions (just google “asha 3:1 model”) and even a webinar on it.

The 3:1 model is essentially three weeks of therapy, followed by a week of collaboration.  This model was created in response to an overwhelming caseload, the fact that time actually spent on each client was not merely 20 minutes/twice a week, and also to be in compliance with the kind of inclusion/collaboration model that also forms part of the base of RtI (and IDEA and NCLB).  The three weeks of therapy are self-explanatory:  the SLP would follow a schedule of therapy like the one s/he has now.  The fourth week, however, is much more flexible.  The fourth week can be used to:  see children who would not benefit from a disruption in weekly therapy, complete paperwork, do evaluations (although it should be noted that it is still recommended that SLPs complete evaluations as they come up, and not “save” them all for the collaboration week), have make-up sessions, hold meetings, develop materials, and, more importantly, collaborate with teachers, parents, other specialists, etc., and get in the classroom to see what the child is doing in the actual classroom setting.  As I mentioned, this was piloted by the Portland School District who at the end of the pilot study ended up adopting this model for their school district.  They reported that had more time to discuss students’ needs, progress, and strategies with parents, teachers, and other specialists which is important when trying to facilitate carryover across multiple environments, not just the therapy room.

The biggest concern for the SLPs in my district, and reported by the Portland SLPs, was the time spent “selling” the model to teachers, parents, other school personnel, etc.  While the Portland SLPs reported that they had no trouble with parents once it was implemented, they did spend some time (e.g. sending out detailed letters about the new service model, holding meetings with faculty, answering questions from parents/teachers, etc.) laying the groundwork for its implementation.  I think this is very important, so that the fourth week doesn’t just seem like “time off” for the SLP.  It would likely be beneficial for each individual outline for themselves and for those who may be concerned just how they plan to spend their time during the collaboration week.  That fourth week and the success of the model truly depend on the SLP’s ability to manage her/his own time.

The SLPs from my school district agreed to begin taking the steps to implement it for the 2010-2011 school year.  I think this model has a lot of potential for positive results.  It seems important to have administrators on board, and to spend time educating teachers and parents about the potential benefits of this model before implementation.  And, of course, once implemented, convincing others of the merits of a 3:1 model by your own actions during the collaboration week.  This model also provides a lot of flexibility, so that, if not all SLPs felt comfortable having a week without therapy, could still continue to see all their clients if s/he so wished.  It also provides the flexibility for each individual SLP who have different case loads and needs to use that time during collaboration week for her/his biggest priorities.  What do you think of this model?  Have you seen it in action?  What do you like about it?  Dislike?  Do you potential for great use or great abuse?

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