SPAA 624 Exam 2
i.e.
"that is" Tom produced one articulation error (i.e., w/r)
GOOD DX
A _______ ___ report should paint a thorough picture of the client's current level of functioning Start tx without doing additional testing Know exactly what the client's strengths and weaknesses are, write objectives, and know exactly where to start with curing level Include specifics of what the client can and cannot do (e.g. Sue answered personal yes/no questions with 95% accuracy. She answered general yes/no questions with 35% accuracy) Include what level of assistance client needed (dynamic assessment) - type of curing needed
Before you start Evaluations
ALL patients MUST have a physician's "order" to be seen before an evaluation is completed! The SLP must review the order for accuracy! --Does it indicate an ST specific service? --Is it signed by the physician? --Does it have a diagnosis? INSURANCE WILL NOT REIMBURSE YOUR SERVICES IF ANY OF THE ABOVE ARE MISSING!!!
Hospital INPATIENT Caseloads
Acute care patients ICU = Intensive Care Unit NICU = Neonatal Intensive Care Unit Pediatric Unit Oncology Unit Stroke Unit Cardiac Care Unit... To name a few! Emergency room patients Inpatient Rehab Unit Patients Transitional Care patients (SNF) Common admissions to the hospital resulting in ST services include: --CVA --TBI --Progressive neurological conditions MS Parkinson's Disease Dementia --Head and neck cancer --Pneumonia and other Pulmonary issues --Premature birth Failure to thrive --To name a few! May be admitted for something unrelated to the cause of speech/language/cognitive/dysphagia services, but the deficits need addressed. --For example: hip fracture, a-fib, surgeries
Hospital OUTPATIENT Caseloads
Adults of Children Stable enough to live at home Some patient live in group homes Some patients live in nursing homes that don't have an SLP on staff. They have transportation take them to the rehab outpatient facilities.
Observation Techniques
Analog Tasks Naturalistic Observation Systematic Observation and Contextual Analysis
Authentic Assessment
Best alternative in many cases Allows for real-life situations and natural contexts Materials can be tailored to reflect culture Dynamic
Completing the Evaluation
Case history information begins with a chart review. You may or may not have a lot of information before meeting your patient Be aware of who else is present, and how reliable their information may be! Make sure the patient is OK with their visitors being present Introduce yourself and why you are there Make environmental adjustments if necessary --Adjust patients bed --Turn lights on --Close door Make sure they can see and hear you!! (glasses, hearing aids, dentures) Be empathetic - treat them like you would want your family member, or yourself, treated Begin assessing your client's social skills as soon as you begin interacting with them Be prepared for ALL levels of functioning! Build rapport: you will need to adjust your "style" or interaction from patient to patient. Have necessary materials --Lists or binders of questions --Objects or pictures - can also use items in the room --Standardized tests - (or subtests) Complete the appropriate portions of your evaluation. Try to find a "system" for you! Gather data as you go Know when to discontinue and when to push forward! REMEMBER CONFIDENTIALITY... BEFORE, DURING, AND AFTER CONTACT WITH YOUR PATIENT!!! Most speech evaluations are completed in under an hour. Write-up is usually done in 30 minutes Writing the report is typically done the same day for inpatients and within 24-48 hours for outpatients. Productivity standards prevents therapists from taking a lot of time when writing reports
Role of the School-Based SLP
Caseload vs Workload Responsibilities SLPs in the schools... Consult Evaluate Assess Provide services Screen Collaborate Develop/Monitor Paperwork (IEPs, school records)
ASD Referrals
Common Components included in ASD testing: Receptive/Expressive Language Assessment Speech/Articulation Assessment Pragmatic Language Assessments: Pragmatic Profile (Appendix from CELF-5) Pragmatic Communication Skills Protocol Test of Pragmatic Language (TOPL) Children's Communication Checklist - 2 (CCC-2) ASHA's Social Communication Benchmarks
Disability and Intervention
Cultural groups have differing views of disability and intervention Having a disability is considered the person's fate and intervention would be considered futile --They may not be motivated in therapy Some groups parents feel personally responsible for a child's disability --Do not discount their feelings and thoughts It is believed a disability is a spiritual gift or punishment --They will not want to deny or change a spiritual gift --If it is viewed as a punishment, they may feel like the disorder is something that the individual deserves Rely on non-Western methods of healing - herbal remedies, massage, hot baths, acupuncture and may be skeptical about your ability to help
Familial Authority
Cultural groups hold different views of familial authority The father is the spokesperson for the family and highest authority. Addressing anyone other than father may be considered disrespectful Sometimes it is the godparents, grandparents, aunts, uncles, or tribal elders who make familial decision
Child's behavior in the company of adults
Cultural groups hold differing views about a child's behavior in the company of adults Children are expected to be seen and not heard Children often do not initiate conversations Expect a high degree of conversational participation from their children
Woman's Role in Society
Cultural groups hold diverse views of a woman's role in society May not respect female professionals May be socially inappropriate for a female professional to make any physical contact with a man (e.g. handshake) or ask a man questions Female caregivers may not respect suggestions offered by a female professional who is not also a mother Women and young girls are primarily care providers for the family. School-age girls may be frequently absent from school or drop out to care for family members at home
eye contact in communication
Cultural groups maintain different views about use of eye contact in communication May be disrespectful for a child to make frequent or prolonged eye contact with adults (perceived as a challenge to authority) Adults avoid prolonged eye contact with other adults
View Time differently
Cultural groups view time differently Arriving on time or answering questions in a timely manner is unnecessary or needless
Recommended Assessment
Culturally appropriate assessment materials Tests client's native language AND English Collection of multiple samples Includes narrative assessment Focus includes ability to learn rather than on what client already knows (helps to r/o language learning disability) Dynamic/flexible Consult with others - referral source, teachers, doctor, etc. Consult with interpreter Sensitivity to culture during interview
Acronyms
DD - Developmental Delay OHI - Other Health Impairment SLD - Specific Learning Disability ED - Emotional Disability LI - Language Impairment SI - Speech Impairment ASD - Autism Spectrum Disorder MD - Multiple Disabilities OI - Orthopedic Impairment TBI - Traumatic Brain Injury CD - Cognitive Disability TOR - Teacher of Record TOS - Teacher of Service CCC - Case Conference Committee
Developmental Delay
DD is a disability category solely for students who are at least 3 years of age and not more than 9 years of age. The age range of DD was recently extended from age 5 to age 9 in the state of Indiana. This was established to allow "more time, if needed, to provide specialized instruction or to determine if another eligibility area might be more accurate to describe the student's disability." DD is a delay of either: Two (2) standard deviations below the mean in one (1) of the following developmental areas OR one and one half (1.5) standard deviations below the mean in any two (2) of the following developmental areas: (1) Gross or fine motor development (2) Cognitive development (3) Receptive or expressive language development (4) Social or emotional development (5) Self-help or other adaptive development
After the Evaluation
Develop your Plan of Care (POC) --Frequency of therapy (how often) --Duration of therapy (length of sessions) Write a summary of findings Develop appropriate short and long term goals Bill your services according to your facility's requirements Summarize findings and recommendations for the patient before you leave. (adjust terms/language used to meet the level of understanding of the patient) Contact the physician if you have any questions or concerns. (Get comfortable with communicating with doctors and other medical professionals) Make appropropriate referrals if necessary. (via documentation or direct communication or both) Re-evaluations - may be necessary if the patient is transferred to a different unit. (Know your facilities policies and procedures)
ICF Components
Functioning and Disability Contextual Factors
Paragraphs
In a DX report, the development of a paragraph may be related to the following: 1. A logical sequence of events --Background information 2. A statement of strengths followed by weaknesses --Test performance 3. A comparison of assessment results related to information from other parts of the evaluation (e.g., other testing instruments or the client interview)
Reminder
In all work settings, inclusion of goals should occur in any evaluation report Include goals in any evaluation report The treating therapist should not have to do additional assessment (Medicare will not pay for additional assessment)
State Program for ages 0-3
Indiana = First Steps, Inc. Family is referred to SPOE (system point of entry) --Family focused system Intake coordinator gathers the case history Evaluation is schedule Evaluation is completed with parent present, typically in child's home to determine eligibility Team of 2 providers (SLP, PT, OT, or DT) completes evaluation Assessment, Evaluation, and Programming System (AEPS) Divided into 6 domains --Gross motor --Fine motor --Adaptive skills (self-help) --Cognition --Communication --Social domains Family and team decide eligibility and goals for IFSP --Goals are written in the family wording If therapy is recommended, family is offered agency to select for service provision
Individual Achievement
Individual achievement is viewed differently among cultural groups Group performance may be valued more highly than individual performance Showing individual achievement, as expected in a traditional testing situation, may be socially inappropriate Value modesty and humility highly
Difference vs Disorder
Legally and ethically a disorder can be diagnosed only when the client demonstrates difficulty in ALL of his/her languages Differences = elective tx (private practice, university clinics) Disorder = therapy (any setting)
The Medical Evaluation
Likely a variation of what you have learned at BSU in the clinic Format will depend on the setting and facility: Computerized documentation with checklists Documentation on the computer that you type in the "blank" areas Handwritten forms that you fill in the "blank" areas Typed "report" style evaluations
Telepractice (Birth to Three)
Population and Setting Considerations The decision to accept assessment via telepractice when determining eligibility is subject to facility/employer/state agency requirements, payer regulations/requirements, as well as independent SLP clinical judgment on a case-by-case basis. Considerations of the language used in the home are reflected in the treatment plan. During this time, some early intervention (EI) programs have reported using assessment tools that include parent interviews.
CR Assessments
Published CR measures commonly used in Speech - Language Assessment --Hodson Assessment of Phonological Patterns -3rd Edition (HAPP-3) ----The criterion that we use to compare and measure our kiddo against are developmental norms --Rossetti Infant-Toddler Language Scale ----We are measuring our client against what we know about typical development ----Cognition, expressive language, and other areas --Voice Assessment Protocol for Children and Adults MLU (mean length of utterance) --Their MLU should be equal to their age Language sample analysis --What types of words the kiddo is using Maximum phonation time Percentage of intelligible words --Play a sample of speech for an untrained listener --They write down what they think the child says --Then compare that to what the child actually said --This results in a percentage
Language Arts Standards
Reading Writing Listening Speaking
Steps from Screen to Evaluation to Treatment
Sequential Steps from Screen to Evaluation to Treatment: referral/inquiry Conduct screen Generate parent permission to evaluate Parent signs permission Evaluation occurs within a 50 day timeline (school days) Complete education evaluation report (send, copy home, or mail) Schedule and hold CCC (case conference committee) meeting to discuss results Develop IEP, if eligibility is determined
Pertinent Screening Tools
Sound Probes World of R CELF-5 Screen Pragmatic Checklists Informal Screening Measures
SLP referrals originate from
Special Education Office for new concerns from students not on caseload Teacher/principal consults New students arrive to school Result of hearing/speech screenings in K, 1st, 4th, 7th, 10th grades All ASD evaluations Developmental Delay - "age-out" re-evaluations RTI workload
Very Important
The label should not drive the service!!! The needs of the student should drive the services!!! Just because a medical diagnosis has been given, doesn't mean the school label will be given (although it is more likely) Remember, eligibility is determined by the CCC. You will play an important role in the placement of a student that you service/evaluate Get ready to collaborate with others on the CCC team. Make friends with your school psychologist!!!
Response to Intervention (RTI)
The response to intervention (RTI) process is a multi-tiered approach to providing services and interventions to struggling learners at increasing levels of intensity. It involves universal screening, high-quality instruction and interventions matched to student need, frequent progress monitoring, and the use of child response data to make educational decisions. RTI should be used for making decisions about genetal, compensatory, and special education, creating a well-integrated and seamless system of instruction and intervention guided by child outcome data. - ASHA Website
Pre-Assessment Research
Understand: --Culture (as a whole and how individuals fit within that specific culture) --Normal communication development associated with the culture ----Sound inventories and development cannot be generalized to all cultures --Personal history ----Do not make assumptions based on a limited amount of information that we might have Without this knowledge, assessment procedures may be inappropriate, and diagnostic conclusions incorrect --We may alienate the patient and ruin the rapport that we have built
Developmental Delay Eligibility
Upon prior to turning 9, every child on your workload/caseload under DD, will be re-evaluated in conjunction with the school psychologist to search for a new eligibility, if needed.
Example
Upon response analysis it is noted that a child used prepositions incorrectly in 6 of 12 responses on a test of oral sentence construction What does this finding mean? What should be done next? Clinical Evaluation of Language Fundamentals (CELF-5) --If the direction is in bold, it include multiple direction items (Number 16) --This assessment also includes modifiers, if gives us an idea about how modifiers impact ability to follow directions
Names
Use proper names rather than "the client" or "client" You can alternate throughout the report with the correct pronoun For adults - Mr., Mrs., Ms., Dr., with the last name
Numbers
Use the word for 10 and under Use the numerical for values above 10 Exceptions... Ages Scores
Reports (in acute settings and rehabilitation unit)
Usually checklist/computerized (rarely a written narrative) --Double and triple check that you don't click the wrong box --Text box may have a limit on number of symbols in a text box Evaluation must be signed by you, flagged for MD to sign in chart Billing and coding must be done by day of evaluation
Speech and Language
What are normal nonverbal and pragmatic communicative patterns commonly associated with this group? What are normal phonological patterns commonly associated with this group? What are the normal morphological and syntactic patterns commonly associated with this group? Semantic patterns? --Vocabulary is highly dependent on experience Is the prevalence of certain medical conditions associated with communicative disorders higher amongst members of this race or cultural group?
Family Life
What is traditional home life like? Do other relatives often live in the same neighborhood? During familial interactions, who is the traditional family authority? Who makes decisions regarding client care? What are the names and titles that are most important to use when interacting with various members of a family?
Re-Evaluation Process
When is SLP asked to evaluate as part of a re-evaluation process? Language testing for all ASD evaluations Expiration of DD and searching for new primary eligibility Testing for DD SLD (typically when a student is not already on your caseload and looking to distinguish between LI and SLD.)
Testing Considerations
Will standard case history and interview questions be perceived as personal and offensive? Challenges? What assessment materials and strategies will be most appropriate? What are some basic words and social phrases you can learn to facilitate a better rapport? Will you need to obtain an interpreter? Interpreter - verbal Translator - written
Norm-Referenced test
_______-_____________ ______ are standardized tests designed to compare and rank test takers in relation to one another. Using a norm-referenced test makes it possible to compare an individual's score(s) with those of a large group of statistically selected individuals—usually of the same age or grade level—who have already taken the test. A norm-referenced score is typically reported as a percentile ranking.
Analog Tasks
___________ _______ involve observation of the individual in simulated or staged communication contexts that mimic real-world events, including peer group activities and simulated workplace interactions.
Criterion-Referenced Test
___________-_______________ ______ are standardized tests that measure an individual's performance against a set of predetermined criteria or performance standards (e.g., descriptions of what an individual is expected to know or be able to do at a specific stage of development or level of education). In educational settings, criterion-referenced tests may be used to assess whether the student has learned a specific body of knowledge. It is possible, and in fact desirable, for an individual to pass or earn a perfect score on a criterion-referenced test. Criterion-referenced procedures can also be developed informally to address specific questions (e.g., understanding of wh- questions, automatic recognition of grade-appropriate words in print) and to assess response to intervention (RTI).
Comprehensive SLP assessment includes
comprehensive speech-language pathology assessment includes these components: Case history, including medical status, education, socioeconomic, cultural, and linguistic backgrounds and information from teachers and other related service providers Patient/client/student and family interview Review of auditory, visual, motor, and cognitive status Standardized and/or non-standardized measures of specific aspects of speech, spoken and non-spoken language, cognitive-communication, and swallowing function, including observations and analysis of work samples Identification of potential for effective intervention strategies and compensations Selection of standardized measures for speech, language, cognitive-communication, and/or swallowing assessment with consideration for documented ecological validity and cultural sensitivity Follow-up services to monitor communication and swallowing status and ensure appropriate intervention and support for individuals with identified speech, language, cognitive-communication, and/or swallowing disorders
Long-term goals
should reflect the highest level of desired function anticipated upon discharge Think hierarchically What is the most complex skill you are trying to achieve within the next ___ months? NOT - Patient will develop age appropriate ___________. DO - within 6 months, the patient will demonstrate the ability to participate in conversational exchanges for up to 8 turns in order to maintain conversations with peers and relate clinical medical and safety information to adults.
Examples of Functional Recommendations
voice/breath support training for increasing volume for conversational speech Education of compensatory word finding strategies due to aphasia Training on use of augmentative communication systems for communication of complex needs and ideas. Determine safest, least restrictive diet consistency due to dysphagia Modified Barium Swallow Study to rule out silent aspiration Referral to ENT to rule out organic voice disorder. Follow-up pending MD recommendations Provide education to client/family members regarding rationale and recommendations for current diet and safe swallow strategies
Person-Centered Outcome
Person-centered outcomes are scored questionnaires that give input on how someone experiences a cognitive-communication disorder. Many are validated, and because they are scored, they can be used to set a functional goal that measures real-life improvement.
Dynamic Assessment
"A method of conducting a language assessment which seeks to identify the skills that an individual child possesses as well as their learning potential. The dynamic assessment procedure emphasizes the learning process and accounts for the amount and nature of examiner investment. It is highly interactive and process-oriented. The following chart compares features of a traditional (or static) assessment procedure to the dynamic assessment procedure." Includes: --Active participants ----Parent participation --Evaluator participates --Is fluid and responsive --Results can have direct implications for intervention by examining the child's response to a mediated learning experience
e.g.
"for example" Mary produced numerous substitutions (e.g., w/r, n/m, t/s, t/k, d/g).
Goal writing in Acute settings
(ICU, CCU, MS) These patients are not medically stable. Their immediate health is a primary concern, SLP therapy is normally a secondary concern. Orders are usually received via computer, at team meetings, by rehab manager Immediate - within 24 hours of when order was written (not when it was received) Flexibility --Working in this setting requires flexibility --The patient may need assessment by multiple professionals (occupational therapy, physical therapy) Chart review - may have very little --If the patient has just been admitted, there may not be much for you to look at. Other times there may be a lot to look through. Notify nursing first - critical!!! --Track the nurse in charge of the patient for that day. --Ask that nurse what they can tell you. --They can give you a heads up on difficult family situations Goal of evaluation: obtain critical information about safety and immediate concerns/care as brief as possible (thorough but brief) --Functional communication (can they convey their wants and needs) --Safety with eating After Evaluation --Notify nursing of results - immediate feedback --Notify the doctor that gave you the order to evaluate --Notify others as needed --Notify MD - may need to request order to treat --Goals are written for immediate needs/concerns -----For communication or eating
Purposes of DX reports
1. Provides an analysis and synthesis of the information obtained through the client/family interview, assessment and clinical intuition/judgement. 2. Venue for recommendations 3. Means of written communication 4. Method of securing special services or reimbursement 5. Reflection of professional integrity and competence of the SLP and of the facility
Pre-Planning is essential
1. Review all available information related to the child - reason for referral (from parent, pediatrician, teacher), current levels in all domains, preferences, etc. 2. Have norms ready - this allows you to know what to observe and elicit 3. Have engaging activities/materials planned and available - consider age and preferences (always have books) - Good to have 2 preferred items and at least one novel 4. Have a simple data sheet prepared that you can have with you during the play --Don't rely on memory or audio recordings 5. PLAN what you will do and say for each activity/material you have included ideas of how you can elicit what you need to gather (more on this later) --Pre-plan so that you can elicit the skills that you need to observe CONSIDER CULTURE --Make sure that the toys are culturally appropriate 6. Consider what cues you will use to make a dynamic assessment - you can figure out HOW to help the child 7. Avoid asking WH questions (unless that is a skill you need to assess) - become the play partner and follow the lead of the child 8. Consider that you are building rapport as well as gathering necessary assessment information - have fun! Include parents/caregiver - observe, elicit, report --You may ask the parent to play with the child and observe them
Telepractice Considerations
ASHA's Practice Portal on telepractice identifies that audiologists and SLPs should --select clients who are appropriate for assessment and intervention services via telepractice; --select and use assessments that are appropriate for the technology and that take into consideration client and disorder variables; and --be sensitive to cultural and linguistic influences that affect the identification and assessment of communication disorders and differences in individuals receiving services via telepractice, which may include collaborating with interpreters. ASHA recognizes that the COVID-19 pandemic is unprecedented and requires unique—and sometimes, less than ideal—measures to assess a person's communication needs. It's critical for SLPs to adhere to the ASHA Code of Ethics and federal, state, and district guidelines regarding telepractice to ensure, to the fullest extent possible, that they are providing high quality services. This includes consideration of the use of interpreters and translators during services to English learners, as needed, to provide effective clinical services. SLPs in all practice settings should also verify state licensure requirements for telepractice and telesupervision to be aware of existing regulations and any recent telepractice policy changes that may impact delivery of audiology and speech-language pathology services.
Chart Review
Admitting information Make sure that you have an order to review (check what it says that you can do) --They may only give you permission to evaluate, not treat --Golden ticket - "speech therapy to evaluate and treat" X-rays (head CT, chest x-ray) Radiology information Dietary section NURSING NOTES
Authentic Assessment
Aka = alternative assessment or nontraditional assessment Also identifies what a client can/cannot do Difference = emphasis on contextualized test stimuli in a realistic/natural setting ___________ ____________ is on-going (throughout treatment) which results in a portfolio of "artifacts" across time --To measure whether our treatment is or is not working --Allows you to change your treatment if it is not working Requires expertise --You have to be knowledgeable about the setting The approach is natural and similar to the real world Allows for flexibility and individuality Clients participate in self-evaluation and self-monitoring Not covered by insurances, etc.
IEP Requirements
Assessment of progress in educational curriculum Social and developmental history Observation in classroom Medical information that is educationally relevant Other assessment information needed to determine eligibility for special education Comment regarding responsiveness to interventions - RTI needs to be administered and proven ineffective before a child is eligible. Goals are based upon educational relevance --Maybe the deficit affects reading, spelling, or social aspects Scope and sequence - curriculum per grade level Life skills for students needing this kind of educational plan/placement --Cognitive related concern
Medical Setting
Audience - MD, NSG, rehab team, caregivers Purpose: provide health care information, prove provision of quality assessment/services for reimbursement and continuity of care, ensure success with ADL Style - brief, more telegraphic, use "client" or "patient" Requirements Primary and treating DX (codes) --The primary diagnosis might have nothing to do with speech therapy (hip fracture) Date of onset Freq/duration POC (Plan of Care) (ST - short term goal and LTG - Long term goal) Certification period Current level of functioning Potential for progress Barriers to learning
Functioning and Disability
Body functions and structures - describes actual anatomy and physiology/psychology of the human body Activity and Participation - describes the person's functional status, including communication, mobility, interpersonal interactions, self-care, learning, applying knowledge, etc.
varying amounts of small talk
Certain cultural groups expect varying amounts of small talk before engaging in the business at hand Rude to jump right to the business without engaging in a satisfactory level of preliminary small talk
Case History and Interview Questions
Certain cultural groups may be uncomfortable with many of the case history and interview questions traditionally asked May be perceived as rude and highly personal --Pregnancy, labor, and delivery Important to first establish a strong rapport (multiple visits)
Testing Practices used
Certain cultural groups may be uncomfortable with some of the testing practices used You may not want to call something a test "I am going to ask you to do a variety of things today. Some may be harder than others. But, that's okay! I just want you to try your best." Cultures that learn by observing May be unwilling to attempt unfamiliar tasks or expect a demonstration first "Testing" may be completely unfamiliar concept
Telepractice (Prior to Initiating Assessments)
Clinicians may want to consider and discuss the following with employers and payers: Any components of an evaluation or assessment procedure that is waived or revised, such as requirements for norm-referenced or criterion-referenced tools Considerations for nonstandardized assessments should be reflected when the client does not fit the norming sample Clinical opinion and functional information obtained by using the client's natural environment, observation (live or recorded), and family/caregiver reports Opportunity or benefit of pre-conferencing with families/caregivers to help gather materials needed for assessment, such as manipulatives or sample videos Considerations for language used in the home, including any needs/requirements for collaboration with an interpreter/translator Critical information needed to establish eligibility and/or develop a treatment plan, and aspects of the assessment that need to be deferred to a later time In addition to the client's clinical presentation, SLPs should consider their skills/competency in techniques such as coaching families; families' understanding and feelings about telepractice services; home/work life responsibilities of parent(s)/caregiver(s); familial norms; and access to technology.
Telepractice (Coding and Payment Policy)
Coding and payment considerations for telepractice services are generally the same as in-person services. SLPs providing telepractice should report Current Procedural Terminology (CPT) codes just as they would if the services were provided face-to-face and follow the same guidelines for appropriate billing. For example, time spent administering nonstandardized tools for telepractice may not be reported using CPT codes requiring standardized tests. ASHA provides additional guidance on coding and payment for telepractice as well as extensive resources on CPT coding for speech-language pathology services. Always verify coverage and payment guidelines with payers before initiating telepractice services.
Selecting and Interpreting Standardized Assessments
Coexisting disorders or diagnoses are considered when selecting standardized assessment tools, as deficits may vary from population to population (e.g., ADHD, TBI, ASD). In addition, standardized tests should be culturally and linguistically appropriate. Standard scores should not be determined if the norming sample does not adequately represent the individual being assessed. It is essential to consider the language spoken and/or dialect used by the child before selecting a standardized assessment. Standard scores cannot be reported when the assessment has been translated. Clinicians select the most appropriate method(s) and measure(s) to use for a particular individual, based on his or her age, cultural background, and values; language profile; severity of suspected communication disorder; and factors related to language functioning (e.g., hearing impairment and cognitive functioning).
Remember
Degree to which an individual has been acclimated into the mainstream culture will alter and shape social rules Avoid stereotyping
Express disapproval in varying ways
Different cultural groups express disapproval in varying ways Inappropriate to contradict others May appear cooperative and agreeable during interview situations; but, may be merely showing courteous respect while having no intention of following through May smile and appear agreeable, even when angry
Contextual Factors
Environmental factors - factors that are not within the person's control, such as family, work, government agencies, laws, and cultural beliefs Personal factors - race, gender, age, educational level, coping styles, variability among cultures (may have an influence on how a person functions in activities of daily living)
Uses of CR Assessment
Examine a particular skill to confirm a diagnosis Identify therapy goals, tasks, stimuli, and/or settings that would be appropriate for the client - identify what a client can/cannot do Track progress over the course of treatment
Reports by Settings
Report style/format will vary depending on your setting/facility and potentially the funding source Report requirements are typically based upon legal requirements: IDEA, NCLB (Every Child Succeeds Act), Medicare/Medicaid, ASHA - state and federal regulations Incomplete, unclear, inaccurate, poorly interpreted reports can have significant consequences --Client may not be eligible for services --Client billed for or denied services --Legal claims --Bad reputation
Standardized Tests
Identify if a problem exists (yes/no) How big is the problem (severity) Should therapy be recommended Need for additional testing Therapy goals should not be based upon responses to test items Standardized tests are not designed to identify items within a domain that are weak or difficult for the client Standardized tests only sample behavior by including just a few items in any specific area Norm-referenced tests are not valid for the objective of planning treatment goals based upon responses Responses can be analyzed for error patterns
Person-Centered Goals
If you're truly focused on meeting real-life needs in speech therapy, person-centered goals will reflect that. You can start by incorporating the phrase "in order to" within your goals. An example goal might look like, "The patient will improve attention for typing ten-digit numbers on a phone in order to successfully dial a phone number on 75 percent of attempts (baseline 33 percent)." As a clinical SLP, you are under pressure to gain important assessment information during a limited amount of time. These person-centered assessment strategies will help you get the information you need to devise an appropriate treatment strategy, all while working within the limits of your allotted assessment time and keeping your focus where it belongs—on the people you treat.
Key Elements of SMART Goals
Impact on functional communication and safety --Do goals aim to improve care and reduce costs through prevention? ----Looking at the whole person ----Being a responsible, ethical health professional --Do the goals increase safety? --Does the intervention increase independence? ASHA endorses International Classification of Functioning, Disability and Health (ICF) for goal writing ICF = classification of health and health-related conditions for children and adults that was developed by the World Health Organization (WHO) and published in 2001 ICF framework can be used in interprofessional collaborative practice and person-centered care Providers are expected to write goals using the ICF framework
Error Analysis
Individual items should not be used for goal setting Errors can be classified into types within and across tests Appropriate and informative when applied to test items that are open-ended Not appropriate for close-ended questions --yes/no questions or true/false questions should not be used Not appropriate for extremely low scores (percentile at/near 1)
Goal writing in Rehabilitation Units
Patient transfers from acute setting or from one unit to another New evaluation is required every time a patient is moved More detailed in nature - more extensive Evaluate with discharge in mind --Home alone --Level of assistance --Family support --Tentative discharge plan After evaluation --Immediate feedback to nursing and others as needed --Communication with the Rehab team (PT, OT) is critical. All therapists need to know: ----Current level of functioning ----Goals for PT and OT ----DC plan
Adhere to the following points
May use professional vernacular (medical, technical, and clinical terminology) with explanations as needed for "audience" = consider who will be reading and gear to the person with the least amount of understanding or the most significant reader Use formal rather than colloquial (conversational language) --Do not use contractions State information in concise and direct sentences Refer to client/family member by name or appropriate pronoun Write a report in 3rd person (e.g., "the evaluator" rather than "I"). Introduce your report with the full name of the client Conclude report with full name of the client (last section of report) Use introductory sentences for new information or paragraphs whenever possible Follow your introduction with more specific information Write a concluding statement for each section or paragraph Report information in logical order (e.g., order of importance or chronological, where applicable) State the positive information prior to the negative information - strengths before weaknesses Use terms such as "appeared," "stated," "seemed," "reported," or "according to_____," when unsure whether or not the information provided is indeed factual When reporting health history, the phrases, "were positive for the presence of _____," or "negative for the presence of _______" enhance cohesion of the report Avoid use of subjective statements, emotional words, or exaggerations (e.g., extremely, terribly) Avoid use of contraction Eliminate phrases such as: along the lines of, due to the fact that, with regard to, is considered to be, that said, having said that, etc. Avoid wordiness - be concise and concrete Give the full names of tests when first mentioned before using the acronym or other abbreviations in the remainder or the report State information in behavioral terms (e.g., "followed two-step commands" versus "is able to follow two-step commands") Difference clearly between information reported by others versus information obtained directly through clinician observation, case history, or some other means --- cite source List all data such as test scores or baseline measure before providing any interpretative statement If concern is stated in background information, you must test that area - report results even if normal If you assess an area - you should have a "reported concern" (will not be reimbursed) If you make a "judgement" in the assessment section, you must have hard data to substantiate it Recommendations must be based upon test results/assessment
Criterion-Referenced Assessment
May/may not be standardized Determine mastery of a skill or content Address content in a specific area Include test items that are intended to cover content in a domain Performance can be presented in raw scores or percentages for interpretation
Outpatient Facility
Most like clinic setting Located within hospitals, ECF, MD office, free standing clinic, vocational rehab, etc. Type of client varies based upon setting Typically has a specific reason for referral and evaluation will be geared toward the reason Usually have 30-60 mins for evaluation Typically a more extensive evaluation, often standardized (SSI) Usually narrative report Determine skills needed to return to prior level of function Goals dictated by above (for adults) If child, goals to improve skills or decrease delays`
Motivational Interviewing
Motivational interviewing, an evidence-based and person-centered interaction style, affects the words you use and how you phrase them. When you put careful thought into open-ended statements, reflections, and other techniques, you can help inspire change and goal-setting in therapy. Instead of using a persuasive-style statement like, "I can see you are having memory challenges and we need to address that in speech therapy," try a reflection like, "I noticed you made a face when you were trying to tell me where you worked and that you said that was a change from normal—tell me more about that." This may inspire motivation to participate as well as establish a stronger, more empathetic working relationship.
Potential Statement
Must also consider including information related to the client's potential for improving on goals Must include a rationale for your decision (Why?) --Good motivation --Familial support Potential for improvement (rehab potential) Typical to state that potential is "good" for goals Don't really use excellent, because there are many aspects that you cannot control Use: good, fair, or poor (poor will not be reimbursed) Must explain WHY you think potential is "good". What are the positive factors? "Potential for improvement is believed to be good based on recent progress and family support." "Potential for progress on goals is estimated as poor based on the client's overall decline in level of alertness." "Addie's potential for improvement on goals is food based upon her young age, parental support, and cooperative nature."
Cultural Biases and Prejudices
Must be aware of personal biases/prejudices that may be prevalent in society (yourself) so that they do not influence the assessment process Ethical obligation to provide a high standard of care Negative feelings should not affect clinical impressions or decisions
Functional Recommendations (goals)
Must include the functional area/s of deficit to be addressed Functional deficit statement --This articulation disorder results in an inability for Sam to adequately participate in educational and social activities in the classroom, as he cannot be well understood by others." --Mr. Tatman's expressive language deficits result in an inability to consistently express his wants and needs Must include how the area/s will be addressed Must indicate a SKILLED SERVICE that is needed --Why you? (as a SLP) --Why now?
Names and Titles
Names and titles used during communicative exchanges may vary among different cultures More common to address certain family members by relationship rather than name If unsure, ask
First Steps/Early Intervention
Narrative report style (like Doe Boy) Background --Pregnancy --Labor --Delivery --medical/health --NBHS (newborn hearing screen and results - usually parent report) ----Refer for hearing if it is a concern --Family history / background ----Primary caregiver ----Siblings with speech and language problems ----Who is in the home Concern Domain specific - parent friendly terms --Fine motor --Gross motor --Self-help (feeding and swallowing) --Cognition --Communication Social --Observations Suggested outcome/goal areas Goals are ultimately formulated by the parent/guardian
Extended Care Facility (ECF)
Nursing home or assisted living Every new admit is screened - swallowing, communication, cognition, and hearing Ask for evaluation order if appropriate May transfer with a written evaluation order already- must be done between 24-48 hours of written order Typically every patient is screened every quarter --Look for any changes in swallowing, communication, cognition, and hearing Determine immediate needs/skills needed for patient to go home Before Evaluation --Know the DC plan --Know the payor source - will dictate evaluation length and treatment duration --With some payor sources you may need to eval and tx in the same session After Evaluation --Plan is written for specified number of days/weeks --Requires MD signature --Treatment times are based on minutes and often determined by payor source, etc.
Three ways to gather information
Observation Be able to make accommodations and try to elicit a behavior Parent report --Ask if they have seen a behavior
Contextual Observation
Observing someone doing necessary tasks can provide further information about how their impairment is affecting participation. Imagine that someone tells you they are having difficulty making phone calls. Is it because: They can't find the phone number? They are pressing the wrong buttons? They have a hard time expressing themselves while talking? They struggle to return to the conversation after not understanding something? Observing a phone call during the assessment only takes a few minutes, yet it provides you with a wealth of information about where to start in therapy to meet this person's needs.
Parent, Teacher, and Self-Report Measures
Parent, teacher, and self-report measures include rating scales, checklists, inventories, and questionnaires completed by the family members/caregiver, teacher, or individual. Findings from multiple sources (e.g., family vs. teacher vs. self-report) may be compared to obtain a comprehensive profile of communication skills. For individuals who speak a language other than English in the home, the clinician needs to gather detailed information about use of the primary language and English. When possible, checklists should be made available in the person's native language to obtain the most accurate information.
Perceptions of personal space
Perceptions of personal space vary across cultures More comfortable with greater amount of personal space and exhibit very limited personal contact during social interactions Close personal space and may be offended if you step away during conversation
Telepractice (School Settings)
Population and Setting Considerations "As a general principle, during this unprecedented national emergency, public agencies are encouraged to work with parents to reach mutually agreeable extensions of time, as appropriate." This statement supports flexibility in achieving timeline requirements as well as opportunities to prioritize evaluations. SLPs must follow state requirements, which include making determinations to inform school district decisions. To date, ED has not issued specific guidance on using telepractice for evaluations. Similarly, when providing intervention via telepractice, it's important to consider federal privacy laws like the Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act (FERPA). During this pandemic, the U.S. Department of Health and Human Services (HHS) relaxed requirements to comply with HIPAA for some videoconferencing platforms; however, relaxation of HIPAA does not impact compliance with FERPA. FERPA usually takes precedence over HIPAA when educational agencies or institutions receive direct funding from ED. One consideration for your school district is whether a statement about allowing the disclosure of personally identifiable information to other parents and household residents during telepractice or virtual instruction should be included in a FERPA consent-to-disclose form.
Telepractice (Modification of Test Materials)
Publisher permission is required to copy, scan, or modify test materials in any way. Permission is given on a case by case basis. Many publishers, including ProEd and Pearson, have issued statements waiving certain requirements during this pandemic, but make sure to check with the publisher before modifying tests. Recording of test administration (such as recording a telepractice evaluation session) continues to be prohibited by most publishers.
Quotation marks
Punctuation is place INSIDE the quotation mark (Mrs. Smith shared, "Sam dislikes the texture of meat.")
School Setting
RTI - IEP based, state-wide computer program Audience: Parents, IEP team, teachers Focus - standards/curriculum based per grade level Purpose: outline communication needs and rx (recommendations) based on academic need, prove provision of quality services per IDEA and Article 7 and ensure academic success Educational relevance Compare to peers - social, emotional or academic standing (to normally developing peers) Must comment on all domains - language (spoken./written, expressive/receptive), speech (articulation, voice, and fluency Article 7 report requirements --Assessment of progress in educational curriculum --Social and developmental history --Observation in classroom --Medical information that is educationally relevant --Other assessment to address exclusionary factors (e.g., hearing impairment) and used to determine eligibility for special education services
School System
RTI - not typical screen, referral, eval process Tier 1 = Universal screening of all students in classroom and monitoring of progress and language/speech Tier 2 = after 6 weeks, students are identified as at-risk or below peers. In-class or small group techniques are put into place to try to get them to where they need to be with their peers Tier 3 = if not progress after 6 weeks, 1:1 intervention is provided Evaluation may be completed in Tier 2 Two formal/standardized assessments must be completed or attempted Conference held within 60 days of referral Case conference to determine eligibility (unanimous - everyone must be in agreement) --Family/caregiver, SLP, Special education director, classroom teacher IEP Article 7
Select Standardized Testing
Rather than obtaining multiple standardized testing scores, consider starting with a specific need the person has and then completing standardized testing that can color your understanding as to how that need can be met. For instance, during the contextual observation activity described above you discover that the problem with making phone calls is poor attention and high distractibility while trying to dial a ten-digit number. This can lead you to focus your standardized testing on attention, which should provide insight into appropriate interventions and strategies to address that need.
Telepractice (Documentation of Assessment Results)
SLPs must state modifications made to test materials, administration procedures, or other aspects of an assessment in the interpretation and documentation of the assessment. This may include skills observed by the clinician versus skills reported by others, use of an interpreter/translator, any behaviors that may have impacted performance and interpretation of results, and recommendations for reassessment.
What does ICF mean for us?
Short - and long-term goals must focus on FUNCTION Select goals that are consistent with the information provided in the report Goals must be measurable and should be: --Developed in conjunction with the patient/family --Specific to the patient's needs, not a preset group of goals used with all your patients --Specific to the setting where services are provided
Functional Short-Term Goals
Should state why you are working on a skill Building blocks required to master the long-term goal Key statements Patient will _______ in order to ________ Patient with ________ so that ________ Patient will _________ to reduce _________ Patient will _________ to prevent __________ Patient will _________ to increase __________ Patient will _________ to decrease __________ NOT - Sam will increase her knowledge of object-functions from 35 objects to greater than 50 objects DO - within 3 months, Sam will increase her knowledge of object-functions from 35 objects to greater than 50 objects in order to carry out at least 10 activities of daily living in her home environment.
harbor generalized mistrust of other cultural groups
Some cultural groups harbor generalized mistrust of other cultural groups May be political driven Important to be aware of this
Telepractice (Standardization)
Some publishers of standardized assessments have developed guidance about administration of tests via telepractice or validated assessments for administration via telepractice. Other researchers have compared the validity of in-person and remote assessment protocols When using a test that has been validated for telepractice administration, document the interpreted scores as you would from in-person administration. Check with the test publisher if the assessment tasks show evidence of in-person vs. remote administration equivalency for administration via telepractice. Verify that your client falls within the norming sample of that instrument. If the test you're using does not fall under this category, the reliability and validity of the test is in question for remote administration. Be sure to document this, including a discussion of modifications, such as collaboration with an interpreter/translator or modification of prompts. Use of a test in a nonstandardized manner may also impact billing of standardized assessment codes Individual test publishers (e.g., Pearson) may offer free access to their digital products, including test stimuli, in response to clinicians' needs during COVID-19
Write functional (SMART) goals
Specific - who, what, where, when, and why Measurable - mastery criteria Attainable - achievable Realistic - support, etc. Timely - what is the timeline for achievement?
Needs-Based Interview
The needs-based interview is a vital portion of nonstandardized assessment and includes a structured conversation that will help you understand the needs of the person you are treating. Remember—you don't have to know every need on the first visit! A good place to start is by discovering two to three needs that will affect their life within the next week. As therapy progresses, you will be able to progress to future needs.
Norm-Referenced Assessment
Standardized Compare an individual's performance to that of other people from the same population Include test items that are intended to differentiate individuals Focus on broad content Performance must be presented as standardized scores for meaningful interpretation
Why do play based assessment?
Standardized assessments capture skills in isolation and in an unnatural manner Play is the preferred supplemental assessment form for young children Play is functional, engaging, and a natural part of the child's routine Play provides an opportunity to assess comprehension of spoken language, expressive skills, cognition, pragmatics, and much more Play-based assessment is a dynamic assessment Play-based assessments can measure skill performance during natural, child-driven play Note - "child-driven play" Play-based assessments add authenticity and contextual benefits to the assessment because they measure objective behaviors during child-driven activities --Standardized tests don't show the child's whole skill level
Standardized Assessment
Standardized tests have advantages Standardized tests are not always appropriate tools for assessment of communication skills Many standardized tests are designed to assess a particular communication skill in isolation - one dimensional approach that detracts from naturalness of communication --They are not the best to assess functional communication Norm referenced or criterion referenced assessments can compliment Delay or disorder, how big or how much?
Static Vs Dynamic Assessment
Static Passive participants Examiner observes Identify deficits Standardized Dynamic Active participants Examiner participates Describe modifiability Fluid, responsive
Transdisciplinary Assessment
Team SLP Classroom teacher PT OT Hearing Impaired Teacher One person plays and everyone else watches and observes
Telepractice (Health Care Settings)
Telepractice in health care settings has not been extensively used in the United States due to the lack of reimbursement from both public and private third-party payers. With relaxed regulations and increased reimbursement options during the COVID-19 pandemic, SLPs in health care settings may have remote service delivery options for the first time. Before starting telepractice in health care settings, ASHA recommends the following considerations: Ensure access to appropriate technology for both patient and provider. This may look different depending on the type of health care setting. For instance, in an acute care setting, there may be a selection of shared devices between different units or care teams. In home health, the clinician or provider may be using their own personal devices, and both access and ability to navigate software platforms should be ensured before initiating services. Ensure availability of extenders who are appropriately and adequately trained. Extenders are crucial in facilitating access to and use of technology, troubleshooting technological issues, and assisting with repairing communication breakdowns. Depending on the setting, extenders could be nurses, nursing aids, rehabilitation assistants, family members, or other staff. Regardless of who is acting as an extender, they need to be adequately trained to facilitate remote assessment without impacting the validity of results. Ensure linguistic access to services. Patients and extenders may require the assistance of an interpreter to appropriately access services. Like extenders, interpreters may need to be adequately trained on facilitation of clinical services. Be aware of any comorbidities that may impact a patient's ability to participate. Across the continuum of care in health care, patients may present with various comorbidities that could impact their ability to fully participate. Concomitant cognitive, hearing, motor, or vision impairments could significantly impede a patient's ability to participate in remote sessions and should be considered prior to initiation of assessment. Ensure proper infection control protocols for shared devices. In the event that a care team is sharing devices between providers or patients, infection control policies and procedures should be in place and followed. Promote frequent communication between care team members. As with the implementation of any new service delivery model, when initiating the use of telepractice in health care settings, communication between all stakeholders is key to successful use of remote service delivery. This is important for the episode of care, and to promote continuity of care and discharge planning as the patient moves through the continuum of care.
Purpose of CR Assessment
To determine whether or not a person can perform a certain task --Can they speak in complete sentences? Rather than how the person performs relative to others Measure designed to assess specific abilities in a particular domain Individual skills and strength and weaknesses
Colon
Used to introduce a statement/paragraph or series He gave the following account: He did the following tasks:
Semicolon
Used to join two independent clauses (two complete sentences) when the clauses are not joined by a conjunction Stuttering is a speech problem; it should not be ignored
Consider
What does the client NEED to be able to do? What does the client WANT to be able to do? --Ask either the client or their family What can the client reasonably be expected to do? What are the BEST and most realistic options for the client? What information do we need to send home or provide in writing? --Think about this primarily in reference to swallowing deficits!
Need to know
What is the subtest/test assessing? Functional implications (2 for each of these individuals) --2nd grader - concepts and following directions subtest ----This child will struggle in school --35 y/o adult/TBI - auditory comprehension ----Depending on their career, auditory comprehension may be an extremely important part of their job Manual typically gives purpose of each subtest but not always the functional implications
Naturalistic Observation
____________ _______________ is observation of the individual in everyday social settings with others, including academic settings. Criterion-referenced assessments may be used during naturalistic observations to document an individual's functional use of language across social situations.
Curriculum-Based Assessment
____________-____________ ________________ is used to determine the language demands of the curriculum and to assess the student's ability to meet those demands. The technique is based on the curriculum the student is currently mastering and may utilize materials being used in the student's classroom. The assessment can come directly from a textbook (e.g., a chapter test), or it can involve the use of probes or other types of direct assessment. Curriculum-based assessment results can be used to develop instructional goals and to evaluate the student's progress in developing competence with the language of the curriculum.
Dynamic Assessment
_____________ __________________ is a method in which an individual is tested, skills are addressed, and then the individual is retested to determine treatment outcome (i.e., test, teach and retest). Dynamic assessment can help distinguish between a language difference and a language disorder and can be used in conjunction with standardized assessments and language sampling.
Language Sampling
______________ _____________ techniques are used to elicit spontaneous language in various communication contexts (e.g., free play, conversation/dialogue, narration, expository speech) and then derive measures (e.g., Mean Length of Utterance [MLU], Type-Token Ratio [TTR], Developmental Sentence Scoring [DSS], clausal density, use of subordinate clauses) to complement data obtained from standardized language assessments.
Systematic Observation and Contextual Analysis
_______________ _____________ and _____________ ____________ involve observation across a variety of contexts (e.g., settings and tasks) to obtain descriptions of language functioning and identify specific problem areas and contextual variables that play a part in the individual's communication abilities. Systematic observation along with contextual analysis can be used to complement findings from other assessment procedures.
Ethnographic Interviewing
________________ _________________ is a technique that uses open-ended questions, restatement, and summarizing for clarification for obtaining information from the perspective of the individual and other people in his or her environment (e.g., family members/caregiver, teacher). The technique avoids the use of leading questions and "why" questions. Ethnographic interviewing can be used to validate other assessment findings. Clinicians should refrain from creating assumptions about individuals or families based on general cultural, ethnic, or racial information. Ethnographic interviewing can be used to gather specific knowledge of the views of clients and their families, including cultural and linguistic variables.
Standardized Assessments
__________________ ________________ are empirically developed evaluation tools with established statistical reliability and validity. A standardized test is one that requires all test takers to answer the same items/questions in the same way and that is scored in a standard or consistent way, thus making it possible to compare the relative performance of individuals or groups of individuals. There are two types of standardized assessment instruments: norm-referenced and criterion-referenced.
Comma
often problematic Before a coordinating conjunction (Mr. Smith had difficulty naming common objects, but he was able to communicate with his family). Serial commas (Sam had receptive, expressive, and phonological deficits)
