Swallowing Evaluations in Long-Term Care: When, Where, Why, How?

Each May, the American Speech-Language-Hearing Association (ASHA) celebrates Better Hearing & Speech Month (BHSM) to provide an opportunity to raise awareness about communication disorders and the role of ASHA members in providing life-altering treatment. Though the theme for 2015 is “Early Intervention Counts,” we thought we would close out May by jumping to the other end of the life spectrum and celebrate geriatrics by providing information on swallowing evaluations used in the long-term care setting. The role of the speech-language pathologist (SLP) in geriatric swallowing disorders can be life-altering as well, and worthy of discussion on this last day of May.

Long-term care studies show that approximately 72% of a speech-language pathologist’s caseload is for the management and treatment of dysphagia. That’s huge! Sounds like in addition to BHSM,  we need a “Better Swallowing Month!” SLP’s in long-term care require advanced assessment and treatment skills to manage the resident with dysphagia. Residents may be in the long-term care facility for short term rehabilitation following an acute hospitalization or may reside in the facility – both may require intervention – and the approach and options for each may be very different.

ASHA has specific guidelines and position statements outlining the knowledge and skills needed by a SLP that provides services to individuals with swallowing disorders. The official statement and document can be found here. Information including the requirement that individuals who practice independently in this area must hold the Certificate of Clinical Competence in Speech-Language Pathology (CCC), practice within their competence level, and are responsible for establishing a systematic plan for the documentation and achievement of proficiencies, is included in the statement.

According to ASHA:

clinical evaluation of dysphagia typically begins with a noninstrumental examination. Subsequently, an instrumental procedure may be indicated. Two imaging procedures typically considered are fluoroscopy and endoscopy (ASHA, 1992). The videofluoroscopic examination is more commonly used in clinical practice and has frequently been described in peer-reviewed literature. This procedure is taught through a variety of means, including university coursework, regional workshops, and on-the-job training. Fiberoptic endoscopic assessment of swallowing functions is gaining widespread use as an instrumental procedure among speech-language pathologists who engage in the clinical management of dysphagia. Like videofluoroscopy, endoscopic assessment of swallowing function is a procedure that requires an advanced level of training and demonstration of knowledge, technical skill, and interpretative proficiency. Therefore, it is important that knowledge and skill requirements for clinical use of this procedure are clearly identified.

Let’s take a brief look at the 3 Swallowing Evaluation types:

1. Comprehensive Swallow Evaluation
2. Videofluoroscopic Swallowing Study
3. Fiberoptic Endoscopic Evaluation of Swallowing

Comprehensive Swallow Evaluation (CSE)

The Comprehensive Swallow Evaluation (CSE), better known as the “Bedside Swallow Exam,” is the first line of defense or examination when assessing the geriatric resident with a potential swallowing deficit. This assessment defines potential etiologic factors and is geared to formulate a tentative hypothesis regarding physiologic or anatomic deficits and develop a tentative treatment plan based on that hypothesis. The intent of the exam is to estimate swallow ability, not disability and may determine the resident’s need, readiness and tolerance for an instrumental assessment.

Videofluoroscopic Swallowing Study (VFSS)

The Videofluoroscopic Swallowing Study (VFSS), also called the “Modified Barium Swallow Study,” or often simply referred to as a “video” is one of the options for instrumental evaluation of a swallowing deficiency. This movie-like x-ray combines food and fluids with barium to allow viewing using small doses of ionizing radiation. The exam is the gold standard of swallowing evaluations, allowing real-time imaging of the dynamic movement of structures from chewing through the trigger of the pharyngeal swallow relative to the bolus position. Click here for ASHA’s information on VFSS.

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Fiberoptic Endoscopic Evaluation of Swallowing (FEES), typically only referred to by it’s acronym “FEES,” has gained widespread use as an instrumental procedure among speech-language pathologists who engage in the clinical management of dysphagia. Like videofluoroscopy, endoscopic assessment of swallowing function is a procedure that requires an advanced level of training and demonstration of knowledge, technical skill, and interpretative proficiency. ASHA has outlined the “Role of the Speech-Language Pathologist in the Performance and Interpretation of Endoscopic Evaluation of Swallowing: Guidelines,” which clearly outlines the responsibility of the SLP in the involvement with the exam. Click here for ASHA’s document on FEES.

Benefits and Limitations

It goes without saying that each test has its benefits and limitations. Clinicians know that the tests are not interchangable and that each test has its’ time and place. There are clinical questions that only the VFSS can answer, and clinical questions that only the FEES can answer. The clinical condition of the resident and the desire to evaluate a specific aspect of the swallow as deemed needed by the SLP, are the components that determine which exam is indicated at the time. What do both tests have in common?

• Both tests should be available for accurate diagnosis and treatment of dysphagia
• Both tests require interpretation by a trained SLP to be used functionally for management and treatment of dysphagia
• Both tests are dependent upon a clear and concise exchange in information between the testing and treating SLP before and after the tests
• Both tests can be over-utilized and under-utilized with a given population
• Both tests have enthusiastic supporters and retractors who often present biased information

To FEES or Not To FEES, That Is the Question

{Sorry, Shakespeare, that was too easy.} The decision of which test, VFSS or FEES, to select for a particular resident must always be made on a case-by-case basis, as there are many variables involved. ASHA’s position and guidelines on instrumental dysphagia exams, which includes fluoroscopy and endoscopy, can be found here. Click here for the document. The SLP is most often the clinician in LTC making the referral for a VFSS or FEES. If the referral for a particular test originates from any professional other than the SLP (dietitian, nurse, physician), the SLP should be made aware of the referral and should be involved in determining the appropriateness of the test. Often facility administration (including some medical directors and LTC physicians) do not understand the clinical difference between the tests and may order the least optimal exam based on other factors, including reimbursement. Administration and finance may not understand the specifics of the tests, however, they are aware that there are circumstances in which sending a resident out for a VFSS would be more costly for the facility vs having an in-house FEES completed by an outside vendor {for example, when a resident is covered under a Medicare Part A stay.}  “We have someone that will come here to do a FEES so we don’t have to send the resident out for a video anymore.” Ever heard this? Payment source and/or reimbursement for the test should never be a factor in determining the clinical necessity or type of test. Members of the interdisciplinary team may not understand the differences between the tests and the role of the SLP will need to include education in this area.

In Summary

The role of the SLP in the long term care setting is vast in scope AND vital to the functional status and safety of the resident. The SLP is plays a significant role in all resident care ranging from those that enter a facility for short term rehabilitation to those that enter for the long term or immediate end of life care. The SLP must take into consideration multiple factors when determining the most appropriate examination for each resident. The VFSS and FEES are both informative assessment tools to provide functional information in which to provide optimal resident care – it is the role of the SLP to determine which test is most appropriate and educate other professionals in the LTC setting as to why specific testing is required. Though reimbursement factors should not influence the clinical choice for an instrumental exam, it is the responsibility of the SLP to know how to appropriately code and bill for each exam, and recognize the fiscal impact of each on the facility and resident. The SLP plays a primary key role in advocating for the needs of the dysphagia resident in the long term care setting and as such, should continue to provide training and education to the long term care interdisciplinary team for optimal communication and resident care.

For long-term care professionals interested in a thorough review of each type of swallowing assessment, including all the risks and benefits, and how each exam is coded, documented and billed for under Medicare Part A and Part B, see the 2 contact hour course located in our course library. A special thank you to Christie Britton-Hare, MS, CCC-SLP, contributing writer,  for making both this article and course possible.

Happy Better Hearing and Speech {AND Swallowing} Month!

In Your Corner,

Dolores