Examples of Audiology and Speech-Language Pathology Services in APMs
Below are real-world practical examples showing the benefits of audiologists and speech-language pathologists actively involved in value-based care: alternative payment models (APM).
Audiology
Adult Example: Hearing Screening for a Person With Type 2 Diabetes
A patient is being seen for an initial hearing test as ordered by their primary care physician (PCP). The patient hasn't had their hearing tested since being diagnosed with type 2 diabetes. The patient reports having progressive hearing loss in both ears, difficulty hearing when there is background noise, and family members telling them that the TV is reportedly too loud. The patient states that they're able to manage their type 2 diabetes with medications and reports recent balance issues with blurred vision. The patient denies falls and admits that their last eye exam was 5 years ago. The patient denies discussing changes in vision and balance issues with their PCP. An audiologic exam reveals a mild sloping to moderately severe sensorineural hearing loss in both ears. Bedside vestibular evaluation indicates that the patient's peripheral balance system is intact. The audiologist recommends hearing aids, and the patient is referred to an optometrist for an eye exam.
Tips on Advocating for Your Services
People who have diabetes are more than two times as likely to have hearing loss, and those who are pre-diabetic have a 30% greater rate of hearing loss than those with normal blood glucose. Yet, audiology is not routinely included in the management of diabetes. Although the connection between diabetes and hearing loss remains unknown, mitochondrial dysfunction, changes in microvascularization, and other reasons may attribute to this connection. These changes can impact both the hearing and balance systems.
Audiologists need to know about this connection—and to routinely ask patients if they have diabetes. By asking a few questions and completing a comprehensive evaluation, you may be the first provider to (a) identify that patient’s risk factor for diabetes and (b) make that referral to their PCP for further investigation.
Pediatric Example: Audiologic Evaluation for a Child With Hepatoblastoma
A 2-year-old child presents to the Emergency Department with complaints of fatigue, fussiness, and poor intake. An X-ray reveals an abdominal mass, and the liver biopsy is positive for hepatoblastoma. The child's oncologist initiates chemotherapy and refers them to audiology for a baseline audiologic evaluation. The parent denies concerns for hearing loss but notes that the child has been receiving speech and language therapy services through the Infants and Toddlers Program for speech delay. The child passed her newborn hearing screening in both ears following a healthy, full-term pregnancy. The child's parent denies any family history of hearing loss.
The child's audiologic evaluation reveals that they will likely have difficulty hearing in many listening situations. The hearing loss is expected to negatively impact further speech and language development as well as educational performance. The audiologist recommends bilateral amplification and relays the evaluation results to the child's oncologist. The care team determines that they will continue to monitor the child's hearing throughout chemotherapy treatment and beyond. After discussing amplification options with the audiologist, the parent orders hearing aids for the child.
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Regarding baseline evaluations, audiologists give priority to patients with newly diagnosed cancer and accommodate these patients with overbookings whenever possible. The oncology providers have a direct line of communication to the audiology administrator/scheduler. Ideally, patients are seen for the audiologic evaluation prior to the initiation of treatment; however, sometimes that is not possible due to the imminent nature of the treatment. Access to in-house medical records makes the medical history easy to review and allows for efficient communication between providers. Consultations via telephone are frequent—especially if hearing loss is present. The team approach (e.g., collaboration between audiology, oncology, and speech-language pathology) is helpful and ensures that the family adequately understands and adheres to the care team’s results and recommendations.
Speech-Language Pathology
Adult Example: Cognitive Impairment for a Person With Parkinson’s Disease
The patient is a 78-year-old woman with a 5-year history of Parkinson’s disease. Within the last year, an associated mild cognitive impairment is diagnosed. Living alone in her two-story home, the patient experiences a fall and a right hip fracture while preparing dinner. After hospitalization for a surgical repair, the patient is admitted to a skilled nursing facility (SNF) for rehabilitation. The patient's personal goals are to return to an independent lifestyle of living alone at home, gardening, caring for their dog, and driving to the store for groceries each week. The patient's results from the Minimum Data Set (MDS)—which is a required post-hospitalization admission assessment for all Medicare beneficiaries—give evidence of mobility challenges and the need for assistance for activities of daily living. In addition, the MDS assessment results indicate that the patient has lost 5 pounds in the last month and needs to have a full cognitive assessment. There is no evidence of delirium or depression. The patient is referred to a speech-language pathologist (SLP) for a speech-language pathology evaluation (“speech eval”). The speech eval indicates that the patient has a moderate cognitive impairment, low vocal volume, shallow breathing, and occasional slurring of words. Review of the medical record indicates that the patient has eaten little since admission to the SNF. The SLP requests orders for a dysphagia evaluation.
Tips on Advocating for Your Services
Despite the presence of a progressive neurological disease, such as Parkinson’s, an aging patient with a recent fracture may not automatically be referred for a speech-language pathology intervention. A referral to an SLP is often overlooked because of mobility issues and difficulty with activities of daily living. Because of the many different payment models emerging in post-acute care, patients are best served by the SLP, who has educated the caregiver staff regarding symptoms of communication and swallowing disorders. Advocacy for evaluations of those who have comorbidities that may not be the direct reason for the admission to the facility not only sheds light on what an SLP offers to the care team, but it also facilitates patient safety and positive patient outcomes.
Pediatric Example: Feeding and Swallowing Services for a Child With Prematurity and Fetal Alcohol Syndrome
A 6-year-old child is referred to outpatient rehabilitation for feeding therapy services. The child has a complicated medical history significant for prematurity and fetal alcohol syndrome. The child receives 100% of their nutrition via gastrostomy tube (G-tube). A recent modified barium swallow study has revealed the child does not present with any pharyngeal deficits that impair their ability to safely consume thin liquids or regular textures. The child has begun accepting small bites of crunchy foods and water. The child's parent has expressed a desire to decrease oral residue after eating foods. During the child's recent feeding reevaluation, the SLP observed decreased lateralization of foods. The child also holds food in their mouth after chewing and before initiating a swallow. The child has an increased amount of food residue in his lateral sulcus and buccal cavity that he will spit out if they feel that they cannot swallow. The child's current medical team includes their parents, a physical therapist, an occupational therapist, an SLP, a gastroenterologist, and a developmental pediatrician.
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It is important to ensure that the entire care team (including the parent or parents) agrees with the ultimate goals for the child. If the long-term plan is for transition to full oral nutrition and hydration, it would be important to have a dietician be a part of the medical care team. The SLP and dietician can work very closely together as the child safely increases their oral intake while maintaining appropriate nutrition and hydration. In this example, the child would also be best served by an SLP who can provide education to all members of the care team across settings (e.g., clinic, home, school, community) so that everyone is approaching the child’s goals in a similar manner—in order to provide consistency and continuity of care.
