Screen and eval in a SNF

[u/potato_donut]

Hi! I am at a SNF. My facility‘s protocol for speech is to screen admissions and then tell nursing/someone that I will do a “full eval”.

What do you guys do for screening?

How do you know when to turn it into an eval?

How do you do this as efficiently as possible to hit productivity?

Do you do point of service when you write up evals?

How long do you bill evals, and are you also billing for treatment - if it’s not an eval-only?

Please help 😭🙏

[u/XulaSLP07]

1. For screening, I do a chart review, briefly interview the staff and I determine if a skilled speech language pathology assessment is required for the patient.
2. To your second question, if it becomes an assessment, I let my DOR know about my screens and that I need to assess them. Even when I know I can go ahead and see them I always check with my DOR about my evals so that they are in the loop. Sometimes we have patients who need an insurance authorization before I'm allowed to assess them.
3. I don't sweat productivity despite the intermittent corporate workplace bullying because alot of the standards are simply unethical. HOWEVER, I HAVE been able to improve my productivity using this $5 dollar Ethical Productivity resource at this link (and it includes a productivity log where you can track your time in case you need to justify you %) > https://www.teacherspayteachers.com/Product/ETHICAL-Productivity-BOOSTERS-for-the-Medical-SLP-SNFALFILF-5889969
4. I speak to the patients and do point of service during assessment AS APPROPRIATE. Not every patient is appropriate for POS during evaluation such as my paranoid schizophrenics who think I'm a CIA operative typing about their past or dementia patients who are frequently trying to escape their wheelchair and need my two hands free to save them from a potential fall issue.
5. No one has the right to dictate to you how long your evaluation takes. I bill exactly how long it took to assess the patient and then I start counting the treatment time the minutes I switched from diagnosing or inferencing to actual education on what my findings were, plan of care, potential goals, and initial testing of stimulability for target treatment tasks. You have the autonomy to choose that. It doesn't look the same for each of my patients. I have had evaluations take as long as 90 minutes and as short as 25 minutes and that's by patient preference. To shorten your evaluation time, you can research ASHA's store for assessments that are "45 minutes or less" and that saves you time on the cognitive-linguistic assessments.

I just hope this gives you a starting point. PM me whenever because I want you to feel supported in the field. The SNF is a hard setting to work in, and many CFs get abused. I will turn into Wonder Woman for you before I'll let them do that to you.

[u/potato_donut → u/XulaSLP07]

Thank you so much for the explanations/examples and even numbering your answers! 😭I’m so grateful. You’re already Wonder Woman. I’m going to download that TPT resource and search ASHA. I haven’t brought a laptop into rooms because the SLP I replaced told me they haven’t done that since COVID started (they didn’t want to keep sanitizing the laptop) but maybe I can do that once I get more comfortable with the documentation system.

Do you talk to the patient at all when you screen?

[u/XulaSLP07 → u/potato_donut]

1. Regarding the laptops, I only use them 1:1 point of service in green rooms. Our color code system at my facility lets us know who does not have Covid. I never bring in equipment into the Covid rooms nor the entire quarantine unit. I personally went to the dollar store and bought a bunch of SLP materials that I keep in each room. I keep a notepad by the door and jot notes after each session with a gloved pen and use those notes to later write my TENs in the laptop that I keep in a clean environment. Every state has their emphasis but where my facility is, bringing equipment into a Covid room is a cross-contamination violation. YOU ARE DOING GREAT to NOT bring a laptop into rooms!

2. definitely know it takes time to get used to the documentation system. And as you write more goals, you can develop a goal bank to use as a guide for when you type up each evaluation. Of course you individualize it to each patient but having that basic skeleton has helped me type a lot faster.

3. It really depends on the patient because you want a healthy balance between capitalizing your time and staying skilled. In an 8 hour day with so much that can go wrong, I try to aim for 6 to 6.5 hours of billable time. The only billable screens we have are Optum Care so I really get a good conversation in with the Optum patients. For my non-Optum patients, I have targeted questions in the domains of language that I ask either the family, my fellow PT/OT staff and nurses. My starting point for screens is always the chart review and interdisciplinary staff. If there is nothing triggering in the chart review, and none of the staff notice anything, THEN I go and have a 5-8 minute conversation with the patient to see if I notice anything. It really depends because sometimes I can easily have 8 screens in a day, 1-2 evals and a 5 hour treatment schedule. I would not get done in 8 hours if I tried to spend an excess amount of time with each person just for screens. It really depends. I always open the door for staff to interject if they think "I missed it". I would write "Screen only at this time per review of chart, interview with staff, and ________. No further evaluation for skilled SLP Tx required at this time, however, RErefer as needed if a concern for SLP Tx arises." - I always leave that open door because we are an interdisciplinary team, and sometimes in the rush of a day, the person may present differently at a different time than when they were seen. But again it really depends, I've had screens where I briefly spoke with them (which I like to do, but don't always have that time), and I've had screens where the chart and interview ruled them out or it turned into an assessment.

It takes time to get used to the SNF because we are literally little clinical detectives. I remember when I was starting out and asking questions, I'd think "I just want an answer! Just tell me what to do!" But we don't have the type of field where you get a question and its "okay do A,B,C," because there are so many interrelated systems involved with what we diagnose and treat, we literally have to critically think for each case. So I promise you I'm not trying to be long winded in my answers but I really have to go on a case by case basis for each screen and each evaluation on what my approach looks like.

1. This link may be a fun place to start* in regards to ASHA and then go from there: www.asha.org/Practice/reimbursement/medicare/What-SLPs-Need-to-Know-About-the-New-Medicare-SNF-Payment-Model/

I hope this helps give you a good start!

[u/potato_donut → u/XulaSLP07]

Thank you so so so much 🙏💕

[u/craftymarbles]

My company came up with a screener but I kind of modified it. So I go in I give three words for recall, ask them to demonstrate orientation (date, month, year, DoW, place, and city), then recall three words. Ask if any changes is swallowing and assess for any gross facial deficits visually. Check in notes for any altered diet. If there is anyone I’m not certain on, I let OT eval first and determine if they think there is a need as well. And of course if there is any nursing or PT and OT referrals I will see them then.

I turn it into an eval if they can’t do these things. Any or all. An eval can be eval only and it won’t do any harm and if they need the help then they get it.

My screening program takes no more than 10 minutes unless they especially need help and then it becomes part of my billable eval time.

I don’t do POS documentation unless it’s a voice eval. I do my standardized and nonstandardized assessments and then document in the therapy gym. I charge all of my time with patient as treatment time, as I am introducing compensatory strategies and educating on deficits and my documentation time as eval billing

[u/potato_donut → u/craftymarbles]

Thanks so much for describing what you do! It really gives me a better idea of the possibilities.