Admission/Discharge Criteria in Speech-Language Pathology

Executive Summary

The ASHA Admission/Discharge Criteria in Speech Language Pathology document was developed to provide general factors for speech-language pathologists to consider when making admission and discharge decisions across practice settings and clinical populations. The criteria were designed as a basis for developing program-specific admission and discharge criteria for children and adults with various speech, language, communication, and feeding and swallowing disorders. ASHA originally published admission/discharge criteria in 1994. These criteria were revised to reflect current research and clinical practice in order to ensure that communication services and supports are provided to all individuals in need. One concern prompting the update of the criteria is that cognitive referencing (i.e., referencing scores on language measures to scores on cognitive measures) was being used to deny speech and language services. Contemporary research and practice question the use of a language/cognitive discrepancy as a criterion for admission or discharge because individuals with similar language and cognitive levels or without certain cognitive skills may still make progress with appropriate communication intervention. Therefore, cognitive referencing is not one of the criteria for admission or discharge in the revised document.

The admission criteria are factors that indicate eligibility or the need for further assessment to determine the need for treatment. Discharge criteria present situations when a speech, language, communication, or feeding and swallowing disorder is remedied; when compensatory strategies are successfully established; when the individual or family chooses not to participate in treatment, relocates, or seeks another provider. It is the clinician's ethical responsibility to review and analyze all aspects of past services in order to identify specific modification(s) that have the greatest probability of yielding improved outcomes and then implement those improvements with ongoing monitoring. A flow chart depicts the sequence to follow when treatment no longer results in measurable benefits and discharge is being considered (see Figure 1).

ASHA developed general admission/discharge criteria to help speech-language pathologists identify patients/clients for treatment; to provide accrediting agency reviewers with information to evaluate service delivery and patient/client management; to assist government agencies, third-party payers, or school districts in the development of regulations and health care reform plans; to provide educators with information about appropriate candidates for speech-language pathology services; and to provide information for consumer education.

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Background

Speech-language pathologists are frequently asked to provide admission and discharge criteria ^[2] for persons with speech, language, communication, and feeding and swallowing disorders to school and health care administrators, third-party payers, and accrediting and regulatory agencies. Determining these criteria is a complex process that is influenced by many clinical and administrative factors, including the etiology, severity, and prognosis of the disorder, and any regulations imposed by federal, state, and local government, accrediting organizations, and education agencies. In all cases, admission and discharge decisions should be consistent with the ethical practices described in the current ASHA Code of Ethics ( ASHA, 2003).

ASHA previously addressed the development of admission and discharge criteria. The document, Issues in Determining Eligibility for Language Intervention, prepared by the former Committee on Language Learning Disorders, focused on economic, administrative, and political issues related to the eligibility requirements of children for language services ( ASHA, 1989). Many of these same issues influence the admission of children and adults for speech, language, communication, feeding and swallowing services. Further, the former ASHA Professional Services Board (PSB) required accredited programs to follow established policies and procedures for patient/client admission, discharge, and follow-up ( ASHA, 1992).

In August 1992, ASHA established the Ad Hoc Committee on Admission/Discharge Criteria to develop a report that would guide speech-language pathologists in developing program-specific admission and discharge criteria for various ages and communication disabilities seen across the spectrum of service delivery settings. Recognizing the range of professional services and practice settings and the diversity of clinical populations addressed by speech-language pathologists, the Committee identified factors that could be used as a basis for developing admission and discharge criteria. The Committee determined that it was neither feasible—given the established time frame—nor advisable to develop prescriptive criteria to replace existing individual program criteria. The identified factors are general so they are applicable to all practice settings and clinical populations.

The original Committee obtained and reviewed existing admission and discharge criteria from various speech-language pathology service delivery programs. The Committee also reviewed the areas of practice for speech-language pathologists, the expected outcomes, and the clinical indicators identified in ASHA's original version of the Preferred Practice Patterns for the Professions of Speech-Language Pathology and Audiology ( ASHA, 1993) to develop the criteria. In 2002, the criteria were updated to reflect the new and revised speech-language pathology practice policies approved since 1994, including the Scope of Practice in Speech-Language Pathology ( ASHA, 2001), the Preferred Practice Patterns for the Profession of Speech-Language Pathology ( ASHA, 1997), and the new position statement and supporting documentation entitled Access to Communication Services and Supports: Concerns Regarding the Application of Restrictive “Eligibility” Policies ( NJC, 2002; approved by ASHA in June, 2002). A related resource is ASHA's Guidelines for Referral to Speech-Language Pathologists ( ASHA, 1998). The referral guidelines were developed to help educate potential referral sources (e.g., case managers, consumers, physicians) about the scope of practice of speech-language pathologists. Referral is often the initiating event leading to admission to speech-language pathology services across settings. Awareness of these referral guidelines may help to increase timely and appropriate use of these services.

A major reason prompting the revision of the 1994 admissions and discharge criteria was a concern that statements in the report could lead to inappropriate denial of communication services and support to those individuals in need. Specifically, the report included as a criterion for admission that “The individual's communication abilities are not commensurate with his or her developmental abilities,” and a criterion for discharge that, “The individual's communication abilities are commensurate with developmental abilities.” However, the use of “cognitive referencing” or a language/cognitive discrepancy as a means of diagnosing language impairment has been seriously questioned (see summary in ASHA, 1996). Nelson ( 1996) indicates that cognitive referencing means that “scores on measures of language development are referenced to scores on measures of cognitive development for the purpose of determining who is eligible for language intervention services” (pp. 3–4). Problems cited in the literature with using cognitive referencing for eligibility decisions include measurement concerns (e.g., measurement error, test reliability, individual variability, and cultural and linguistic assessment bias), theoretical concerns about the relationship between cognition and language (e.g., language may exceed cognitive level), and lack of empirical support for the use of cognitive referencing (see Casby, 1996; Cole, 1996; Lahey, 1996; Terrell, 1996). In fact, individuals with similar language and cognitive levels or without certain cognitive skills may still make progress with appropriate communication intervention ( NJC, 2002). The NJC position statement was written in response to concerns that communication supports and services were being denied to those in need based on restrictive and inappropriate eligibility criteria. The statement and accompanying documentation ( NJC, 2002) emphasize that eligibility criteria should be based on individual and functional needs rather than on a priori criteria such as discrepancies between cognitive and communication functioning and absence of cognitive skills purported to be prerequisites. Based on recent research findings and contemporary policy statements, the revised criteria do not use cognitive referencing as a basis for admission or discharge.

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Admission to Speech-Language Pathology Services

In general, individuals of all ages are eligible for speech-language pathology services when their ability to communicate and/or swallow effectively is reduced or impaired or when there is reason to believe (e.g., risk factors) that treatment will prevent the development of a speech, language, communication, or feeding and swallowing disorder; reduce the degree of impairment; lead to improved functional communication skills and/or functional feeding and swallowing abilities; or prevent the decline of communication, and/or swallowing abilities. The decision to admit an individual to speech-language pathology services in a school, health care, or other setting must be made in conjunction with the individual and family ^[3] or designated guardian, as appropriate. Listed below are factors that indicate eligibility or the need for further assessment of a person's communication or feeding and swallowing abilities to determine the need for treatment. Eligibility for services or for evaluation is indicated if one or more of these factors is present:

1. Referral from the individual, family member, audiologist, physician, teacher, other speech-language pathologist, or team (e.g., interdisciplinary, educational management) because of a suspected speech, language, communication, or feeding and swallowing disorder.

2. Failure to pass a screening assessment for communication and/or swallowing function.

3. The individual is unable to communicate functionally or optimally across environments and communication partners.

4. The individual is unable to swallow to maintain adequate nutrition, hydration, and pulmonary status and/or the swallow is inadequate for management of oral and pharyngeal saliva accumulations.

5. The presence of a communication and/or swallowing disorder has been verified through an evaluation by an ASHA-certified speech-language pathologist.

6. The individual's communication abilities are not comparable to those of others of the same chronological age, gender, ethnicity, or cultural and linguistic background.

7. The individual's communication skills negatively affect educational, social, emotional, or vocational performance, or health or safety status.

8. The individual's swallowing skills negatively affect his or her nutritional health or safety status.

9. The individual, family, and/or guardian seeks services to achieve and/or maintain optimal communication (including alternative and augmentative means of communication), and/or swallowing skills.

10. The individual, family, and/or guardian seeks services to enhance communication skills.

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Discharge From Speech-Language Pathology Services

Patient/client discharge from treatment ideally occurs when the individual, family, or designated guardian, and speech-language pathologist as a team conclude that the communication or feeding and swallowing disorder is remediated or when compensatory strategies are successfully established, as in the following situations:

1. The speech, language, communication, or feeding and swallowing disorder is now defined within normal limits or is now consistent with the individual's premorbid status.

2. The goals and objectives of treatment have been met.

3. The individual's communication abilities have become comparable to those of others of the same chronological age, gender, ethnicity, or cultural and linguistic background.

4. The individual's speech, language, communication, and/or feeding and swallowing skills no longer adversely affect the individual's educational, social, emotional, vocational performance, or health status.

5. The individual who uses an augmentative or alternative communication system has achieved optimal communication across environments and communication partners.

6. The individual's nutritional and hydration needs are optimally met by alternative means (e.g., percutaneous endoscopic gastrostomy), and swallow is adequate for management of oral and pharyngeal saliva accumulations.

7. The individual has attained the desired level of enhanced communication skills.

In some situations, the individual, family, or designated guardian may choose not to participate in treatment, may relocate, or may seek another provider if the therapeutic relationship is not satisfactory. Therefore, discharge is also appropriate in the following situations, provided that the patient/client, family, and/or guardian have been advised of the likely outcomes of discontinuation.

• 8. The individual is unwilling to participate in treatment; treatment attendance has been inconsistent or poor, and efforts to address these factors have not been successful.

• 9. The individual, family, and/or guardian requests to be discharged or requests continuation of services with another provider.

• 10. The individual is transferred or discharged to another location where ongoing service from the current provider is not reasonably available. Efforts should be made to ensure continuation of services in the new locale.

When considering discharge in situations other than those described above, it is the clinician's ethical responsibility to review and analyze all aspects of past services in order to identify specific modification(s) that have the greatest probability of yielding improved outcomes and then implement those improvements with ongoing monitoring. ^[4] The flow chart depicts the sequence to follow when treatment no longer results in measurable benefits and discharge is being considered (see Figure 1). Specifically, the clinician should insure that the following factors have been addressed: (a) appropriate intervention goals and objectives were specified; (b) sufficient instructional time was provided; (c) current and suitable intervention methods or materials were used; (d) meaningful and functional performance data were collected and analyzed on an ongoing basis to monitor and evaluate progress; (e) appropriate assistive technology or other technology supports were provided, when necessary; (f) a plan to address the needs and concerns of culturally/linguistically diverse families (e.g., use of interpreter or translator) as they affect participation in communication services was designed and implemented ( ASHA, 1983); (g) relevant and accurate criteria were used to evaluate intervention; and (h) health, educational, environmental, or other supports relevant to communication interventions were provided. In addition, when provision of treatment that includes all of these factors is beyond the expertise of an individual clinician or the clinician's recommendations are not acceptable to the individual, referral to professionals with specific expertise in the area of concern should be made prior to discharge. Situations relevant to the criteria include the following:

• 11. Treatment no longer results in measurable benefits. There does not appear to be any reasonable prognosis for improvement with continued treatment. Reevaluation should be considered at a later date to determine whether the patient/client's status has changed or whether new treatment options have become available.

• 12. The individual is unable to tolerate treatment because of a serious medical, psychological, or other condition.

• 13. The individual demonstrates behavior that interferes with improvement or participation in treatment (e.g., noncompliance, malingering), providing that efforts to address the interfering behavior have been unsuccessful.

Each program should have established policies and procedures for following the patient/client after discharge. Follow-up is necessary for a variety of reasons, including the fact that circumstances may change in the individual's environment, new treatment options may become available, or the individual may respond differently due to maturational or motivational changes or new life transitions.

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Conclusion

These criteria were developed as a guide for speech-language pathologists in all settings when considering initiating or discontinuing services for persons with speech, language, communication, feeding and swallowing, and related disorders. They may be used as a basis for developing more specific admission/discharge criteria to meet the particular needs of a school, health care, or other program. By identifying general admission/discharge factors for speech-language pathologists, the criteria also help speech-language pathologists identify patients/clients to include on their caseload; provides accrediting agency reviewers with information to evaluate service delivery and patient/client management; provides guidelines to government agencies, third-party payers, or school districts in the development of regulations, health care reform plans, and so forth; provides educators with consistent information to share with students in determining appropriate candidates for speech-language pathology services; and provides information that can be used for consumer education.

Notes

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