Blog Entry 2! Assessment in a SNF 📝

Since post 1, I have been learning about how to better manage my time in the SNF. By this, I mean that I have been taking more control over which patients we see and at what time we see them. My supervisor has been "letting the reigns go" a bit and allowing me to make decisions such as how long each treatment session should be and how to optimize the limited time I have with each patient. This has honestly been challenging for me, as I would say time management skills are an area I still need to brush up on quite a bit. 

However, my supervisor has been extremely encouraging to me in this learning process. In the month that I have spent under her supervision, I can sincerely say that I have become more confident in areas that I was previously unsure about prior to this placement - including dysphagia and cognitive-communicative treatment and assessment. 

We typically follow the same assessment journey each time we evaluate a patient. Here are the steps we take to assess our patients at a SNF:

1. We either receive or create a referral for new or existing residents at our facility. Referrals, since I have been at our facility, have either been from our nursing staff or created by us from new arrival charts. We will see referrals from nursing stating that a patient has been coughing excessively or is bolus holding during meals: this is a dysphagia referral. Most of our cognitive-communication patients we have identified through performing new resident evaluations or screenings upon their arrival to our long-term care facility (LTC).

2. Once the referral has been made, my supervisor and I will complete a chart review of the patient and gather any pertinent information that we can input into their documented evaluation report on the computer such as: patient date of birth/age, sex, current medical diagnoses, medications, and type of insurance. 

3. Then, once we gather all the information we can prior to our session with the client, we then decide which evaluation would be appropriate to administer according to their history, diagnosis, and current signs or symptoms occurring. For dysphagia patients, we have been conducting oral examinations and completing written/paper evaluations such as The Dysphagia Outcome and Severity Scale (DOSS) which gives an indication of the dysphagia severity. For clients with cognitive-communicative needs, we have used a few different assessments such as the Functional Linguistic Communication Inventory 2nd edition (FLCI-2), the Mini-Mental State Examination (MMSE), or the Brief Cognitive Rating Scale (BCRS) combined with the Global Deterioration Scale (GDS) to assess cognitive-communicative deficit severity. 

4. We then determine the patient's dysphagia or cognitive-communicative deficit severity as indicated by the evaluation tool and write the report using the online documentation system. During the last portion of this step, we will write the patient's goals as evidenced by observations we made during the evaluation session. For example: For dysphagia, if we notice the patient exhibits lack of impulse control or excessive coughing post swallow when taking drinks, we will either write a goal for the client to take single sips or begin implementation of an adaptive cup for drinking which will limit the amount of liquid the patient is receiving while taking a drink. For cognitive-communication, if we notice the patient has an extremely hard time attending to the task at hand, we will write a goal for them to practice sustaining attention to task for a set number of minutes that we deem achievable for the client. Ultimately, we make many observations while assessing and write goals that correlate with those observations.

5. After the goals are completed, the final step of assessment we complete is writing any orders we need to if they are warranted. For example: when we create a goal for an adaptive cup, we will then write an order for that cup to be used from here on out for that patient and give a copy of it to the dietary staff and alert them of the reason why we are implementing it. Same for if we deem a liquid upgrade or downgrade due to patient coughing during meals excessively. We would write an order for the upgrade/downgrade and submit it to the dietary staff in the same manner. 

Although the SNF is my favorite practicum placement by far - I will say, one downside about it is that I do not get to experience the joys that are Modified Barium Swallow Studies (MBSS) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) evaluations. As these tools are typically only found in community clinics (FEES) or hospitals (both FEES and MBSS), we do not get to administer such assessments to patients for dysphagia at our SNF. However, some patients may enter our facility with MBSS results we can use to base our decisions on if warranted. Despite not being able to complete a FEES this semester, I have just experienced this past week my first Voice evaluation! We assessed a patient due to concerns about his vocal quality, and upon observation, noted that his voice sounded very wet and weak (almost like a whisper). We completed a short s/z ratio exam on him by timing how long he could hold out the /s/ and /z/ sounds. This was the first time I had ever attempted a Voice evaluation, so it was very exciting to be allowed the opportunity to do so this week :) 

Overall, I would say I have an easier time administering cognitive-communicative evaluations versus dysphagia assessments. I believe this is due to my need to brush up on my knowledge of the phases of swallowing and what takes place during each one. However, my confidence will continue to grow throughout my placement here at this SNF and with years of experience post-graduation, but for now, I look forward to the remaining days at my facility and with my awesome supervisor who is gracious to me beyond my wildest dreams! Super thankful for that. 

I want to always end on a positive note! So today I will state something I am grateful for - my supervisor!! She is awesome & one of the most knowledgeable SLPs I have ever met. She leads me with such grace and patience. I completely lucked out with her as a supervisor this semester and believe I will leave this placement with the most confidence I have ever had because of her help. So a HUGE shoutout to Lindsay 🗣️ She is an absolute star ⭐️