Does “Wet Voice” Actually Mean Dysphagia?

Speaker0:
[0:15] Hi, everyone. I'm Emily.

Speaker1:
[0:17] And this is Eva.

Speaker0:
[0:18] And you're listening to Speech Talk.

Speaker1:
[0:20] We're your research book club so you can do evidence-based practice in practice. Before we get started, Emily and I just had an awesome opportunity being guests on How to Be Patient with Preston and Margaret. We got to answer all of their SLP questions, get into some real talk about medical ethics, and somehow ended up deciding whether or not Preston should let his cats eat rocks because it's their preferred diet. So some clinical insight and some conversational chaos. Go ahead and give it a listen. We'll put in the YouTube link below. And I think this is our first time showing our faces on air.

Speaker1:
[0:54] Anyways, hope you guys hear it.

Speaker0:
[0:56] So let's start talking. Eva, not fun. Just what's up? What's going on?

Speaker1:
[1:03] Clinically, I feel like this week I had a ton of 60-minute sessions with my patients, which was just this, like this deep breath of fresh air, like, whoa, I can just sit here and be present and deal with whatever is happening. Like your patient going hypotensive and you're like, okay, hold that dizziness and feeling like you're going to fall out of your chair. What button do you push for help? And turning it into an active training moment. And it worked. It was great. The wife was there. So we're able to have it be... Very integrated situation where the patient got the chance to practice. It was very clear to us that this is actually a much bigger safety risk than we had previously realized. Like, when he has hypotensive symptoms, he does not initiate getting help. He was like, no, I'm just feeling lightheaded and my vision's getting increasingly blurry. And I was like, oh, I'm so glad you said that out loud. What do we do next? And then the wife was very pleased because she was like, at home, his eyes roll back and we just kind of have to catch him. And so she felt like, that we were targeting his specific needs, that this is maybe going to be better when he goes home, that he'll start initiating for asking help. And I think the only reason we had the space to do it is because we got to sit there for like 60 minutes and work through the entire situation as it unfolded.

Speaker0:
[2:33] Wow, that's amazing. That should be the trademarked reason as why we should not have 30-minute sessions. Like, why shouldn't we try and fit our three to four goals in 30 minutes? That's why. Because we're not targeting real things. We're having to contrive all these situations in 10-minute spurts.

Speaker1:
[2:59] Yeah, exactly. You're like, okay, so a real-life situation is likely not going to play out in the next 10 minutes. What is something that we can mock create that will simulate a real life, you know, experience.

Speaker0:
[3:12] But don't take too long because I have to get to my next patient.

Speaker1:
[3:16] Yeah, exactly. Exactly. How about you, Emily? What's going on?

Speaker0:
[3:22] So my student is in the Bahamas and I had to retake over my whole caseload and I hate it. I miss her. It's so nice to be able to have extra time to do notes and to do the admin stuff and uh now I'm back to training craves training memory strategies I'm like oh, I'm going to need a student all the time. Not saying that, like, you know, she's taking over all of my work, but she does. She's really good. She does a lot. So. Yeah.

Speaker1:
[3:56] Well, kudos to her. That means she's growing as a clinician if you have to fill her shoes and you're like, oh, this is work again.

Speaker0:
[4:04] So sad. And I'm going to be so sad when she's all done in like, I don't know, another six weeks. Oh, wow.

Speaker1:
[4:11] Okay. With that said, what is going on with our episode today, Emilia? you're like fired up about this so i'm i'm like and cue

Speaker0:
[4:21] Emily yeah go off typically we don't do this just a little behind the curtains moment of speech talk we record and the there are producers and everybody are working on our episodes weeks sometimes months ahead of time we always have these way prepared in advance. But just this past week, Pathia's Health, which is the largest provider of instrumental studies to skilled nursing environments, closed down. They just filed bankruptcy and closed. They sent out an email saying like, so sorry, if you have any CEUs that you need to get done, like, you have the next month, and that's it. So... I don't know. I almost feel like a scorned girlfriend. Like, what do you mean? You're just done. You're just leaving? Since when? I didn't even know there was a problem. You didn't even text me. Like, what?

Speaker0:
[5:32] Do I have a say in this? Do I have a say on whether or not we break up? Like, why is this a thing? So, I don't know. It was just, it was very, it's not even kind of, That's very sudden. And now, not only me, but all of the surrounding speech therapists in my area are going to have to figure out who are we going to get instrumentals from, how we're going to do that. And convincing our buildings to sign new contracts with new businesses is a mess. It's all a mess.

Speaker1:
[6:07] So I'm going to back us up just a little bit, which is to say, who is Pathios? So Patheos was formerly Carolina Speech, and they both provide mobile fees, which is the type of instrumental swallow study where they put a camera up your nose and into your throat and watch you swallow, and modified barium swallows where they watch you eat basically on x-ray. They have you swallow some fluoro contrast, barium, mix in with food, and that way on an x-ray we can see what's going on. So they were the biggest national provider. And Emily and I have both worked at facilities that highly relied on Patheos Health. And... What was so great was that they came to you. You didn't have to send your patient out of the facility. You could schedule, you know, around your patient caseload. And they were really fantastic providers. So now that they're kind of out of the picture, quite abruptly, everyone is trying to find out who is your fees provider locally. Do we need to start sending patients to hospitals? How are we going to afford that? So, within the clinical space, it is kind of creating some waves.

Speaker0:
[7:26] Big waves. Huge waves. All right, guys. Got to take a nap. Let me breathe for a second, recollect my anger, and form it into interesting sentences for you guys.

Speaker1:
[7:42] Okay, so this week we're doing something a little different. We have one research article and one op-ed, kind of how-to style article. The research article was Listening for Dysphagia, Voice Quality Sequelae of Material in the Airway. And the other one is by George Barnes. It's called The Case for Instrumental Assessments.

Speaker0:
[8:02] Yeah, the second one is not technically research.

Speaker1:
[8:06] So using both of these, we want to show one, why access to both fees and MBS is important for the field. And two, how to build a roadmap towards getting access, in particular, to fees in your building. We're going to start with Article 1 and then go to Article 2, and hopefully we paint a cohesive picture that is relevant to what's going on right now in the field.

Speaker0:
[8:29] If not, send us some comments and we'll try to explain better.

Speaker1:
[8:34] Seriously. All right, so a quick recap on what the instrumental studies are. First, we have FEES. Emily, do you know that acronym off the top of your head? I'm always like fiber.

Speaker0:
[8:46] Yeah, it's a fiber optic endoscopic evaluation of swallowing. Wow. Very small camera. Yeah, very small camera goes through your nose. Kind of feels like a heavy COVID test, but not as bad because the goal is not to scrape the inside of your nose. And it just sits right above that dangly thing in the back of your throat. And then while you swallow, it records it. So we can go back and review.

Speaker1:
[9:21] And Pathios, formerly Carolina Speech, I did their fees training. I went to Durham, North Carolina, and I got scoped 20 times. And I scoped other people a total of 20 times. And everyone felt so bad because I was very pregnant. and I am sensitive. So it made me tear up and never was like, do I have to make the pregnant woman cry? It was a great learning experience. And that for me at a personal level is part of the reason I was like, oh man, I can't believe they closed because I did their training and it was really phenomenal. Anyways, the other swallow study is MBS or Modified Barium Swallow. It's sometimes called video fluoroscopy. In both cases, it's the same thing happening. You're in front of an x-ray machine, you're being fed food or liquid that has fluorody in it. Sometimes it's barium, and that shows up on an x-ray. So that's how we can kind of trace what's going on in your anatomy as you swallow.

Speaker0:
[10:21] Most people, when they don't know what I'm talking about, just call that a cookie swallow. Oh, you had a cookie swallow done? Yeah.

Speaker1:
[10:28] Oh, I have not heard that. That's cool.

Speaker0:
[10:30] Everybody around me at least calls it a cookie swallow.

Speaker1:
[10:34] That's funny. Okay, so let's get into Article 1, Listening for Dysphagia by Kathy Weldon, Lisa Kelchner, Noah Silbert, and David R. Rule. David W. Rule. And I have to say, I had one of those moments where I was like, oh, you know you're a nerd where when you read this research article and you're like, oh, it gave me shivers. I was like, Emily and I are like so deep in sharing research that when I feel like I hit a really good piece, I'm like, oh, my God.

Speaker0:
[11:05] Can I candidly say that that's never had, like, never gotten the good shivers from a research article?

Speaker1:
[11:14] I literally, when I finished reading it, talked to my husband and I was like, oh, my God, the message section was fire. Anyways here was the premise gotta

Speaker0:
[11:26] Keep it on your nightstand.

Speaker1:
[11:27] That's right can't keep the research on my nightstand um because voice abnormality is associated with a swallowing disorder it's been a clinical indicator of dysphagia and there's research to support that there's a correlation between potential swallowing disorders and vocal quality Yeah. And you see this all the time in the field, right? Yeah.

Speaker0:
[11:51] Immediately. As soon as someone is eating and they start to have that wet, gurgly vocal quality, we're like, uh-oh, something's wrong. Something is not moving the way it should.

Speaker1:
[12:03] Exactly. So clinicians, we use this all the time to justify dysphagia services or textural downgrades. And when I read this, I thought, yeah, I'm like always listening for wet vocal quality post-swallow. Those words are in my documentation all the time.

Speaker1:
[12:18] But then in this paper, here's where the trauma unveils. They did a research review and found that a lot of the foundational literature that supports this exact logic in clinical decision making, it turns out that they were done doing video fluoroscopy, so that x-ray swallow, and the judges were rating their vocal quality not during the swallow study. So they're basically listening to a patient's voice and being like, hmm, I think they have a swallow disorder. Then later on like hours or a days later they're getting that x-ray swallow days later exactly that should be your reaction like why is this so just like so far apart so why are these two factors so important one an x-ray swallow study is done from the side you're kind of looking at um i don't know how to say it like a side view of a person um a sagittal a sagittal ooh a sagittal plain swallow, where we can see food go along its journey, but we can't actually see where the bolus or the swallowed material is on the vocal folds. Is it like right on the top? Is it along the sides? And all because it's at that lateral view.

Speaker1:
[13:40] And then also, the audio and the video analysis were not synced. Like, this is a huge problem. You're trying to say, hey, they sound funny when they swallow something, but I'm not listening to them talk while I'm watching the video.

Speaker0:
[13:55] I'm still caught on how it's days later. How is that? How did they get it back days later? Are they not like doing the modifieds themselves? Are these different raters?

Speaker1:
[14:06] Yeah. So like basically people were flagged for like wet vocal quality and then later on they had a swallow study done.

Speaker0:
[14:15] And they didn't test vocal quality during the swallow. That wasn't like a, I mean, truthfully, that's not a typical test that people do, like say different words when they're talking because, The goal of a swallow study is not to see how your voice sounds. Majority, it's to see if you have a swallowing disorder, not if you have a wet vocal disorder.

Speaker1:
[14:38] Right. And so while there's nothing wrong with that process, right, we do that all the time. We hear something at a bedside swallow. We're like, hey, we need more clarity. So we send them out for a video swallow. The issue is based on this information, you can't say that when they have food in their throat, they sound like they have a wet voice. Because those things weren't happening at the same time. There was no recorded audio with the video. Anyway, so this brings us back to the fact that vocal quality is a potential indicator and not necessarily a diagnostic tool for determining dysphagia. We need the video to actually say, hey, is the vocal quality because there's food or liquid in the throat?

Speaker0:
[15:22] Well, because that kind of jumps into that fees part, right? Because of fees, you can see. You do make people talk whenever they're eating and drinking. And where a modified, you're cutting someone's head basically in half from the nose back. And you're seeing that half a face just where the food is going and not where it's hanging out. And you're not seeing secretions. You're only seeing whatever is being able to that barrier because it's picked up on the x-ray. It reacts to the x-ray. So a fees is better in seeing those secretions. You can see mucus. You can see pooling of other things that are not being swallowed.

Speaker1:
[16:09] So that's kind of the history between why we associate wet vocal quality with dysphagia because of these studies. So they took that context and they were like, how would we do this research today? And they opted for fees, just like you said. They're like, we need to see the vocal folds and what's happening to them. And they synced the audio and the visual. So they had people put the camera up their nose and into the throat, had them go, eee, drink some blue dyed drinks and then say, eee, again. And then they had people listen to that and rate, do you think this voice sounds wet? rough? Does it sound severe to you? And then they took people's ratings and they judged it against what was actually happening in the video. And my favorite part was that the answer is everyone, all the judges did really poorly.

Speaker1:
[17:06] There was huge discrepancy between the raters and who thought what was severe or wet or hoarse. It turns out the biggest indicator for wet vocal quality was not the dyed liquids. It was people's own secretions, their mucus, their saliva. So when we hear wet vocal quality, you're way more likely just hearing saliva in someone's throat and not actually what they've been eating or drinking. For me, I was like, holy smokes, That's like one of my biggest clinical indicators. I think that this is huge also because what you think, Emily, and what I think we hear could be completely different.

Speaker0:
[17:45] So much we're taught to rely on our clinical judgment on how our clinical brains see X, Y, Z. But our clinical judgment is 100% shaped by our experience as clinicians. So if I have, you know, experience working with maybe trach and vent patients or I have a high level of dysphagia caseload constantly, maybe my perception of a wet vocal quality is going to be way lower than somebody else's perception of a wet vocal quality because that's not something that they always deal with. So I think it's having that basis in general and that basis that's supported through our schooling that we should be we should be using our clinical judgment. Our clinical judgment should be X, but our clinical judgment is guided by our clinical experience. So, yeah.

Speaker1:
[18:41] And like, for example, you and I work in predominantly in geriatrics and we know that as people age, their voice changes. So somebody at 55 who has a, quote unquote, a wet vocal quality or a rough vocal quality would be very different than me saying, I don't know, that older guy in his 70s or 80s, his voice sounds the same. Because to me, I'm like, that sounds like old person voice, which, fun fact, is called presbyphonia. That's old person voice. And also, I might say, hey, I think this person has a wet vocal quality. And you might come in and say, I don't think so. So it's not something that's universally perceivable, which makes it so subjective and why we need the visualization to, like, be official.

Speaker0:
[19:26] Did they say whether or not the people who had more wet vocal quality did have more aspiration events?

Speaker1:
[19:33] That brings us to the next thing. There was no correlation between having more secretions in your airway and an increased swallowed material in the airway. So just because you have more like pooling saliva, which is likely what you're hearing when you hear wet vocal quality, that doesn't carry over and be like, well, if they have pooling saliva, they're also likely to have pooling food. Nope, no correlation there. I was just like,

Speaker0:
[19:59] Wow, glowing minds.

Speaker1:
[20:01] Exactly. That's why I said this article was fire. And there was no correlation with increased swallowed material in the airway. So increased risk of aspiration. So like hearing wet secretions does not indicate that there's an increased risk for aspiration. I was like, what? What do I even know anymore?

Speaker0:
[20:24] I know that means if that's true, then we need to take that off of our education that wet vocal quality is an indicator. If it's not.

Speaker1:
[20:34] How is it? Well, okay. So I think this is really where research sparks questions. And we can jump into your article, Emily, because after I read this, I was like, what, how do I even think about our dysphagia diagnostic process, right? We always go from bedside to recommending instrumental and then we get feedback from that and we make decisions. Or at least that's how it's supposed to work. And the George Barnes article you chose says, he cites another article called Aspiration Risk After Acute Stroke, Comparison of Clinical Examination and Fiberoptic Endoscopic Evaluation of Swallowing. Ta-da! Anyways, that article says, SLPs may over-diagnose dysphagia in as many as 70% of non-instrumental evaluations. So as many as 70% of our bedside swallows, we may be going, oh, that's wet vocal quality must be dysphagia.

Speaker0:
[21:32] Yeah, when you think about research that we just looked at, you start to think, no wonder we're going primarily based on people's voices after they swallow, and we're just hearing them talking with saliva. Not even a big deal. They're just old and they got throat pockets.

Speaker1:
[21:51] Oh man, throat pockets, that is a phrase. I think we should do like an informal labeling of the pharyngeal anatomy and in the piriform sinuses, just write throat pockets.

Speaker0:
[22:07] It's where they keep their keys.

Speaker1:
[22:13] Anywho, and the flip side of that is that he points out that if we're relying on our hearing, we're way more likely to miss a silent aspiration when material is getting into the airway with no obvious signs, no coughs, no throat clears, things like that.

Speaker0:
[22:30] Yeah. I mean, that makes sense because if there's no clinical signs of aspiration, then why would we treat? If there's no reason to suspect aspiration because it's silent, wouldn't pick somebody up on a bedside? Can't treat what you can't see.

Speaker1:
[22:49] Yeah. Those things you're like, oh, are your eyes watering because it's dry in here or because your body is secretly reacting to food in the airway? You know, like, can't tell.

Speaker0:
[22:59] And the masking, the people will say, oh, it's allergies.

Speaker1:
[23:04] Allergies. I have something in my eye. You know, they're trying to be like, my eyes are watering. There must be a reason. You know, they don't know.

Speaker0:
[23:13] I thought of something sad.

Speaker1:
[23:15] I thought of something sad suddenly. So, yeah, I think we should now move deeper into the George Barnes article. Emily, you want to bring us in?

Speaker0:
[23:24] So his article actually starts out trying to understand the lay of the land in skilled nursing, that SLPs, or speech-language pathologists, find it difficult to access instrumental swallows, what the facility's balance sheet looks like, and the effects of swallowing data on clinical decision-making. Overall, he ends up building a kind of how-to guide for building a case to your facility on how to get access to instrumentals.

Speaker1:
[23:55] Oh my God, getting access to instrumentals. Not the first time we've talked about this or ranted about this.

Speaker0:
[24:01] It never is. And it'll never end. Now that Pathias is gone, I had just calmed down, Eva. I had just calmed down.

Speaker1:
[24:13] I know. You were all fired up. Then we talked about research. You calmed down because that's how research makes you feel. And now you're all ramped back up.

Speaker0:
[24:22] There wasn't even a chart involved.

Speaker1:
[24:24] Oh my God, actually, this article had great charts. I didn't show them to you.

Speaker0:
[24:29] That would probably give me the shivers.

Speaker1:
[24:31] But yeah, I mean, you and I have talked, God knows how many number of times about going to your boss, going to a manager, going to nursing, just every day trying to remind people, hey, we got to get this done. We got to get this done. This person needs to swallow a study. Like that is what's clinically recommended at this moment.

Speaker0:
[24:48] So our buddy George talks about consolidated billing being a hindrance. So this is where we're getting into the facility's balance sheet as it comes to nursing home stays. So boiling it down to this, under Medicare Part A, so our skilled patients, the facility's...

Speaker1:
[25:09] You know, it's going to be a long section where we're like, OK, let's start under Medicare Part A. It's like, all right, buckle up, y'all.

Speaker0:
[25:17] Just smack your face a couple of times so we can get through it. Wake up a little. It's a short paragraph. So facilities receive a predetermined daily payment based on the patient characteristics. They call this a case mix. Don't worry about that. I won't quiz you on it later. What they're basically doing is anticipating the costs around those patient characteristics. So if somebody comes in with a whole bunch of comorbidities and everything going wrong with them and they need wound care and definitely speech and a whole lot of physical therapy... They're predicting that cost to get that reimbursement. So if they're not predicting a very high cost.

Speaker1:
[26:06] And then the patient becomes more expensive during their stay. It turns out they're not getting enough money to pay for the cost of that patient. So that's why understanding all of the potential medical needs of your patient before they get into the facility is important. Because once they're in the facility, like your daily rate has already been determined. Mm-hmm.

Speaker0:
[26:31] And that Part A, skilled stay, the facility is responsible for paying nearly all the services the patient receives. There's like a couple that they don't, but it's not really within our scope. Pretty much everything that speech does is under this consolidated billing. So consolidated billing. All the billing for that one person is put together and billed by the nursing home. So if you need someone like an outside provider, like a fees company, they need to come in. They cannot bill Medicare directly. They bill the facility. The facility pays them. And the facility includes that cost within the overall reimbursement. Yeah.

Speaker1:
[27:16] And if they didn't anticipate that, then all of a sudden this is, you know, an added cost on top of what they thought they were going to need for this patient.

Speaker0:
[27:24] And I can just tell you the amount of times that they have anticipated the need for a fees is zero. I would bet that across all facilities. Ain't nobody anticipating a need for a swallow study. They're always like, shocked Pikachu. I mean, this person came in with a history of dysphagia. Dysphagia. Oh, do you need another swallow? Yes, they're on a pureed nectar diet. I'm going to need a swallow study if they're going back to their regular thin diet before they go home. Cindy.

Speaker1:
[27:57] That's so good. I love it when you really lean into your anger. I don't want you to be angry, but I do enjoy it a little bit.

Speaker0:
[28:08] We'll see how we do next week when I get back on my OCD medications.

Speaker1:
[28:15] Congrats.

Speaker0:
[28:16] Yeah, I know.

Speaker1:
[28:16] So since we're talking about costs, let's get into it a bit.

Speaker0:
[28:19] So how expensive is it to have a patient at the facility with a diagnosis of dysphagia? Well, in research terms, it's statistically significant.

Speaker1:
[28:30] I think we're borrowing that phrase pretty generously. It feels statistically significant.

Speaker0:
[28:38] It feels right. So in the hospital setting, so not us, but it equates to about a little more than $5,000 more per year compared to patients without dysphagia. In a community setting, about $8,600 more per year. I don't know how you would say that. And then patients who are NPO, so nothing by mouth, they have tube feeds either in their nose or in their stomach or in their arms or veins, could be as much as $54,000 per year.

Speaker1:
[29:13] That's a lot. Yeah, that's a lot. That's money right there. Why do our dysphagia patients cost so much more? Well, there's a lot of cost drivers. So one, diet-related expenses. Modified diets like providing ground-pureed foods, thickened liquids, enteral feed formulas, supplements, those things are all expensive. There's increased staffing needs. You need feeding assistance, monitoring, supervision. And finally, there's likely medical complications because these people do have associated risks with their dysphagia, like aspiration pneumonia, malnutrition, weight loss, dehydration. So overall, more risky patient. They need more support in terms of their medical equipment, which is, you know, I'm including their food with that. So, yeah, the bills add up.

Speaker0:
[30:04] I feel like, too, in facilities, they don't, when they see a patient who's coming in with a dysphagia or NPO, they might see those automatic costs of the eternal formulas or what that is going to be. But they don't think of maybe even all the extra supplies, like a suction toothbrush to make sure, extra oral care supplies, all of the little costs. And I think really the increased staffing needs, that's a big one too, because their minimum staffing requirement, so like a facility only keeps in as many, trained as TNAs as they are minimally allowed to have. So the lowest number the facility can have. So if someone needs, if they need more people to come in during meal times to make sure people are being fed, that's not something that they are automatically thinking about. And that is a, that's a huge, that's a huge financial cost.

Speaker1:
[31:10] Yeah, I would say the next concern is hospital readmissions. One, hospital readmissions are expensive. And two, it kind of dings the facility. Your skilled nursing ranking is qualified by several metrics, one of which is how many times do people get readmitted to the hospital after they come to you? Because that is potentially or probably related to your quality of care there. How good are you at rehabbing people at your skilled nursing facility. If you're sending people back to the hospital all the time, maybe you're not that good at it. At least in theory, that's kind of the question behind readmission rates for skilled nursing in terms of their ranking.

Speaker0:
[31:55] No, that's definitely how hospitals view skilled. If a hospital is sending a person, to your skilled nursing facility and they're just coming right back, Like, you're about to be put on the do not call list. Like, you're going down the rankings for referrals because they don't want the patients coming back in worse shape. They want their patients going home and getting better. Another problem with hospital readmission is, in general, lost revenue. So in a skilled nursing environment, when somebody is sent out to the hospital, that bed is on hold for that person. They're not automatically discharged and able to get another readmission into their spot. They hold that bed. I've seen a bed hold for as long as a month. So during that time, That's all lost revenue. While that person is in the hospital, you can't bill for anything. So they have an empty bed.

Speaker1:
[32:55] That they can't fill.

Speaker0:
[32:57] That they can't fill and they can't charge all of the services that they planned on charging for that bed.

Speaker1:
[33:03] Yeah. Okay, what's next?

Speaker0:
[33:05] There's another program where it's like a value-based purchasing program where the facilities are being tracked on hospital readmission rates. And if they're lower than the national average, they actually get a bonus. Like a kudos for being good at helping people get back on their feet. So they want people to stay in the facility, get better, and go on to normal life so they can get this bonus and recognition for being a good facility.

Speaker1:
[33:38] Skilled nursing facilities have a lot to try to balance financially. And what I like about this George Barnes article is that he kind of gives you the lay of the land in that capacity. He's showing you all these things they have to balance. And then he goes, so let's turn this into a reason to get fees or modified barium swallows. Like, let's turn this into a supporting rationale for how we can improve patient care and subsequently not have so many of these kind of unexpected costs.

Speaker0:
[34:12] So that checklist. to be able to present this cost-saving avenue, right? We're still costing the facility money, but in the long run, saving them if we can, Bring them over to our side of things. Bring them to the dark side.

Speaker1:
[34:34] Are we the dark side?

Speaker0:
[34:35] I don't know. It feels like it sometimes.

Speaker1:
[34:40] I will say, so kind of big picture, what does that look like? If what you're trying to pitch is, hey, if I can just verify the presence of dysphagia or if I can verify that they don't have swallow problems, guess what? We don't need that modified diet. We're about to save a lot of money.

Speaker0:
[34:59] And I don't have to treat. You don't have to bill for my services if there's nothing to be charged for.

Speaker1:
[35:07] Yeah. Okay. So give us the rundown on this kind of like motivation checklist Barnes came up with.

Speaker0:
[35:13] So step one, find out how much money we're getting for an admission. Step two, know the cost of the instrumental. If you're going to ask for money, know what you're asking for.

Speaker1:
[35:27] Exactly. And then three, go back to your caseload records and figure out how many people who have dysphagia are on thickened liquids, they have texture modifications, basically all those things associated with a dysphagia patient.

Speaker0:
[35:42] Eva, do you keep track of your patients typically like this? Do you look back onto your caseload and say, this is a, I had six patients this month who had thickened liquids or...

Speaker1:
[35:54] No, and I think a large part that has to do with like the fast turnaround at my facilities. When I worked at a place that had more long-term care, I would periodically, like once a quarter, go through and see who is still on Thick and Liquids and go, hey, let's see if we can get you off. Let's try, you know, you plateaued before. Maybe we can make some progress and try and get you off your modified diet.

Speaker0:
[36:19] Yeah, I think that's kind of how I have my setup too. I keep a diet log. Anyone who comes in, I mark down what their diet was when they came in and then any changes just to keep coming back to those people.

Speaker1:
[36:34] You're going to end up being a DOR one day.

Speaker0:
[36:36] Oh, no, I won't. Knock on the wood. No, I won't. That's too much. I feel like this is a lot. Like, this is a lot. The last thing I want to go do is sit in extra meetings.

Speaker1:
[36:52] I digress and then you also want to talk to your kitchen manager because they're going to be the people who have the costs monthly of the amount of pre-thickened liquids you know or annual costs and so now we're trying to paint this picture of what does it cost to have them be on these diets what is the cost what are we getting from insurance for these patients and we're starting to kind of show this balance sheet and you can start to show the facility, hey, if we're able to get half of these patients off of their thickened diets, look at what that would add up to in terms of savings for us.

Speaker0:
[37:30] So again, just to sum up those points, You want to advocate for that instrumental study so we can reduce the long-term cost of being on speech therapy forever, reduce the cost of extra modifications or staffing needs for that patient.

Speaker1:
[37:52] If it's a cog meal patient, like somebody who has dysphagia because of cognitive issues, we can maybe get them to have reduced staffing needs. If we can get the person to, you know, eat an appropriate rate, swallow safely and independently without having somebody tell them to. Mm-hmm.

Speaker0:
[38:11] And like Eva was talking about in that first article, our bedsides really, really aren't enough. We need to have that instrumental study to see what we need to be targeting. What is dysphagia and what is not?

Speaker1:
[38:29] And getting somebody, we heard that one of those biggest costs is an NPO patient. Not only does it dramatically improve quality of life to be able to eat food from your mouth where you can taste it. It's yummy. But it's also hugely cost saving. So, you know, by providing the services we are trained to do, we're also like helping the facility meet their needs. And isn't that synergistic?

Speaker0:
[38:56] Yeah. If that patient, that NPO patient is costing the facility 50 grand or more per year, like, can we get that in a bonus? If we get so many, if we get, for each person, we get off NPO.

Speaker1:
[39:10] Can we get a bonus?

Speaker0:
[39:12] A $5,000 bonus.

Speaker1:
[39:14] Yeah, talk about a lining incentive. And to just kind of put a bow on that, the access to mobile fees environment has changed with the closure of Patheos. Sad to see y'all go. We think you were doing great work. And everybody start looking for mobile fees in your region. And if you've always thought about opening mobile fees, now is your time to shine go figure

Speaker0:
[39:39] That out yes yes now is your time to shine and, I have always been very impressed by the Pathias workers who have come to my facilities. But man, am I scorn about how they went out.

Speaker0:
[39:58] It's bad. I mean, they went bankrupt. So all of their equipment is being sold off. All the providers are now out. And I don't know, Pathias, you could have given us a warning. You could have a 30-day notice or something. Anything.

Speaker1:
[40:22] I'm just feeling deep in her feelings about it.

Speaker0:
[40:26] I'm in my feelings about it. I'm sad for the providers and sad for the patients. Happy, I guess, for the people who have independent businesses because they're about to be booming.

Speaker1:
[40:36] Yeah, seriously. Well, I was like, and we thought we were going to end maybe on a positive note. And then we got all sad again.

Speaker0:
[40:44] I don't think we've, how many episodes have we ended on a positive note?

Speaker1:
[40:48] I think we always try.

Speaker0:
[40:50] We try, but then you remember that I'm on the podcast and it goes.

Speaker1:
[40:58] Don't do yourself a disservice. Okay, I will say happy ending note. I do think that there are some small mobile fees providers in my area who haven't really been able to get off the ground very much. They're very small providers. And hopefully this is going to be a really great opportunity for them. And I really look forward to hopefully watching their businesses grow. And maybe this will inspire hospitals to develop, you know, mobile fees departments. A lot of folks are doing more outpatient work or trying to create mobile clinics. And this would be a great avenue for them as well.

Speaker0:
[41:31] Yeah that is actually a good positive note eva you're right hashtag reframe taking down the conglomerate and bringing back small business i like it, You've been listening to Speech Talk.

Speaker1:
[41:44] Thank you, everyone, for coming to listen to our research book club. Until next time, keep learning and leading with research.

Speaker0:
[41:50] If you like this episode and you want to give us some love, please rate us on your favorite podcasting app. Leave a review and tell the world, because as podcasters, our love language is in positive affirmations.

Speaker1:
[42:02] And if you like listening to us, you may like more podcasts from our network, Human Content, like How to Be Patient, Bendy Bodies, Knock Knock High with the Glock and Fleckens, and psychiatry bootcamp. If you have a research topic you want us to cover or you have episode comments, clinical experience you want to share, or just want to send us some love letters, send us an email at hello at speechtalkpod.com.

Speaker0:
[42:26] If you want even more speech talk content, check out our website at speechtalkpod.com where you can find all of our resources we made for you, copies of articles covered, and Eva's blog following these topics and more.

Speaker1:
[42:39] We're your hosts, Eva Johnson and Emily Brady.

Speaker0:
[42:42] Our editor and engineer is Andrew Sims.

Speaker1:
[42:44] Our music is by Omar Ben-Zvi.

Speaker0:
[42:46] Our executive producers are Aaron Corney, Rob Goldman, and Shanti Brooke.

Speaker1:
[42:51] To learn about Speech Talk's program disclaimer and ethics policy, verification and licensing terms, and HIPAA release terms, you can go to speechtalkpod.com slash disclaimers.

Speaker0:
[43:03] Speech Talk is a proud member of the Human Content Podcast Network.