Byline: Melody Sheldon, M.A.,CCC-SLP owns and operates Southwest Rehabilitation, a private practice in Coos Bay, Oregon. Since 1989, she has been providing services to acute care hospitals, extended care facilities, hospice, home health agencies, transitional homes, and to pediatric and adult patients in her clinic. In an effort to provide continuity, Melody Sheldon developed the Dysphagia Complaint Scale, which she and her staff use with patients and their families to rate the severity level of the problem throughout an episode of care.
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A Goal Bank is a place where contributors can “withdraw” a goal and make a “deposit.”
Evidenced-based practice as defined by the American Speech and Hearing Association as the integration of clinical expertise, external scientific evidence, and patient perspectives to provide high-quality services reflecting patient needs.
Patient-centered care revolves around the patient. The idea is that the patient knows best how to meet their needs, and it is the patient’s view that correlates with outcome or satisfaction.
Functional outcome measures (FOM) provides a means to quantify changes in the patient’s functioning throughout an episode of care using a common language among patients with the same diagnosis.
Dysphagia Patient Complaint Scale (DPCS) is a visual analog scale that measures the patient’s complaints ranging from 7 (being the best or no impairment) to 1 (the worst or 100% impaired). Each of the patient’s complaints are listed at the time of initial visit and provided a score. Throughout the treatment process, the patient reevaluates each of their complaints and adjusts the score as indicated.
Accountable Care Organizations (ACO). The idea is to encourage health care providers to work together to treat an individual patient across care settings using a patient-centered focus to promote evidence-based medicine with patient engagement; i.e., quality care.
Goal setting is a tried and true way for the patient and therapist to define a path from a problem to a solution. The concept of setting goals is not new. The process of defining a goal and steps towards its achievement can be traced back to philosophical writings by Aristotle in 384-322 B.C. In recent years, the Goal Setting Theory introduced by Edwin A. Locke, and further defined by Dr. Gary Latham, has provided the S.M.A.R.T. (Specific, Measurable, Assignable, Realistic, Time-related) objectives. In his work, Latham showed that clear goals and appropriate feedback provides motivation and, in turn, improves performance. Many speech pathologists have adapted Locke’s theory and incorporated Latham’s S.M.A.R.T. objectives when it comes to establishing speech and language goals.
Goal banking, on the other hand, is a relatively new concept. Goal banks can be found on sites throughout the Web allowing therapists to withdraw and/or make goal deposits. With the advent of electronic medical records, goal banking has made the process of goal writing easier. Most educational settings have developed goal banks where the therapist can copy from the bank and paste into their IEP. Major long term care and medical records companies have stock or pre-made goals with check lists and/or “fill in the blank” properties in an effort to ensure that the established goals meet the requirements of their intermediaries. Medicare, for example, has specific guidelines as to the contents of an acceptable goal. Each must be measurable, with a time frame and use terminology that reflects the clinician’s technical knowledge, that indicate the rational, type, and complexity of activity, and report objective data showing progress toward each.
The process of putting together a goal with or without the availability of a goal bank remains challenging to say the least! The therapist has to identify the problem or problems and the steps necessary to achieve each goal. In addition to specific content, intermediaries are requesting a “patient-centered” approach. In other words, the patient’s concerns need to be included. A plan of care that is evidence-based; that is, integrates a treatment protocol vetted by research or sound clinical judgment is also required. To complicate matters, Medicare has developed incentive programs for health care providers called Accountable Care Organizations (ACO). The idea is to encourage health care providers to work together to treat an individual patient across care settings using a patient-centered focus to promote evidence-based medicine with patient engagement; i.e., quality care.
As our intermediaries rely on documentation as a means of assessing quality of care, measurement becomes difficult. Most facilities have a unique approach to goal writing based upon their electronic medical records program with a list of boxes or pull down menus to choose from, making patient participation difficult and tracking progress across a continuum of care next to impossible. In an acute care setting, the dysphagic patient’s goal may read, “The patient will consume the least restrictive diet consistency meeting nutritional and hydration needs with a minimal risk of aspiration during his hospital stay.” This same patient at the extended care facility may have a goal that states, “The patient will tolerate thin liquids without s/s of aspiration during 3 consecutive sessions.” In the out patient setting, “The patient will use the supraglottic swallow during intake of thin liquids 90% of the time with minimal cuing.”
How do we stop or at least reduce the constant changing and structure of goals from one setting to another and provider to the next? How can we incorporate the patient’s perspective in our goal writing through out the course of treatment? How do we make goals that are comparable from facility to facility? At Southwest Rehabilitation, we have a unique setting where patients are often seen throughout their rehabilitation process beginning in an acute care hospital, during extended care, in the home, and eventually as an out patient. We’ve devised a goal bank on our website for our therapists to draw from allowing consistency between providers and from one facility to another. We are able to cut and paste long and short term goals with pull down menus that meet most of our patients needs. As a result, our therapists are able to track patient progress using a standard protocol from setting to setting throughout an episode of care. The benefits are huge! We can discern, given the use of the Dysphagia Patient Complaint Scale (DPCS), if the patient is seeing progress. The same problems are addressed from setting to setting and the approach or plan of care remains the same.
While this is not possible in most settings, it would benefit all providers if dysphagia goal banks were added to other organizations or entities, such as the American Speech-Language and Hearing Association (ASHA) and the National Foundation of Swallow Disorders (NFOSD). This would allow health care providers to work together to provide consistency in treatment of individual patients across care settings and quantify change in the patient’s functioning throughout an episode of care using a common language among patients with the same diagnosis.
As Medicare providers, we are asked to use Functional Outcome Measures, inserting G-codes during the billing process, which helps to quantify changes in the patient’s severity level throughout an episode of care. These codes, however, don’t address the problem, goal and plan. What if we had a common format with a specific set of evidence-based procedures to draw from, a list of typical problems expressed by dysphagic patients to use, and measurement options found to be successful in measuring patient concerns?
Goal banks and their use in all settings will help speech therapists stop or reduce the constant changing of goals from one care provider and rehabilitation setting to the next. While individual providers can provide examples of goal banks in individual practices, it is ultimately a common goal bank repository from organizations, like ASHA and NFOSD, that we really need.