EPISODE 240

[0:00:00] MD: Okay. For this wayward episode that was supposed to go out July 4th, but Erin and I couldn't get her life together to record, I apologize. I am grateful for y'all, for listening and hanging with us while we have the best attempts in getting things out on time, but there's a wiggle room. For everybody that's listening that was waiting on this episode to drop a little while ago, I apologize and take partial credit. Erin also gets the other partial credit, but thank you, thank you. 

I hope that these gratitude entries into the universe are Ð theyÕre making you sit back and look and reflect on all of the little things that we can be grateful for every single day. There's a lot. Such as the perfect blend, the perfect ratio of the guava papaya tea from Panera with their unsweet tea, because that's a sweet spot. It's not too sweet. Just the right level of unsweet. It's amazing. I guess, I am grateful for y'all and for hydration for today's episode. Thanks.

[INTRODUCTION]

[0:01:23] MD: Hi, folks, and welcome to First Bite: Fed, Fun, and Functional. A speech therapy podcast sponsored by speechtherapypd.com. I am your host on this nerd venture, Michelle Dawson, MS, CCC-SLP, CLC, the All-Things PFDs SLP. I am a colleague in the trenches of home health, early intervention right there with you. I run my own private practice, Heartwood Speech Therapy here in Columbia, South Carolina. I guest lecture nationwide on best practices for early intervention for the medically complex children. First BiteÕs mission is short and sweet, to bring the light, hope, knowledge and joy to the pediatric clinician, parent, or advocate.

[0:02:10] EF: By way of a nerdy conversation, so there's plenty of laughter, too.

[0:02:14] MD: In this podcast, we cover everything from AAC to breastfeeding.

[0:02:19] EF: Ethics on how to run a private practice.

[0:02:21] MD: Pediatric dysphagia to clinical supervision.

[0:02:25] EF: And all other topics in the world of pediatric speech pathology. Our goal is to bring evidence-based practice straight to you by interviewing subject matter experts.

[0:02:34] MD: To break down the communication barriers, so that we can access the knowledge of their fields.

[0:02:40] EF: Or, as a close friend says, ÒTo build the bridge.Ó

[0:02:43] MD: By bringing other professionals and experts in our field together, we hope to spark advocacy, joy and, passion for continuing to grow and advance care for our little ones.

[0:02:55] EF: Every fourth episode, I join them. I'm Erin Forward, MSP, CCC-SLP, the Yankee by way of Rochester New York transplant who actually inspired this journey. I bring a different perspective, that of a new-ish clinician with experience in early intervention, pediatric acute care and non-profit pediatric outpatient settings.

[0:03:15] MD: Sit back, relax and watch out for all hearth growth and enjoy this geeky gig brought to you by speechtherapypd.com.

[DISCLOSURE]

[0:03:30] MD: Hey, this is Michelle Dawson, and I need to update my disclosure statements. My non-financial disclosures. I actively volunteer with Feeding Matters, National Foundation of Swallowing Disorders, NFOSD, Dysphagia Outreach Project, DOP. I am a former treasurer with the Council of State Association Presidents, CSAP, a past president of the South Carolina Speech Language and Hearing Association, SCSHA, a current Board of Trustees member with the Communication Disorders Foundation of Virginia. I am a current member of ASHA, ASHA SIG13, SCSHA, the Speech-Language-Hearing Association of Virginia, SHAV, a member of the National Black Speech Language Hearing Association in NBASLH, and Dysphagia Research Society, DRS.

Additionally, I volunteer with ASHA as the topic chair for the Pediatric Feeding Disorder Planning Committee for the ASHA 2023 Convention in Boston, and I hope you make it out there.

My financial disclosures include receiving compensation for First Bite Podcast from speechtherapypd.com, as well as from additional webinars and for webinars associated with Understanding Dysphagia, which is also a podcast with speechtherapypd.com. I currently receive a salary from the University of South Carolina in my work as adjunct professor and student services coordinator, and I receive royalties from the sale of my book, Chasing the Swallow: Truth, Science and Hope for Pediatric Feeding and Swallowing Disorders, as well as compensation for the CEUs associated with it from speechtherapypd.com. Those are my current disclosure statements. Thanks, guys.

[0:05:28] EF: The views and opinions expressed in today's podcast do not reflect the organizations associated with the speakers and are their views and opinions solely.

[EPISODE]

[0:05:37] MD: Okay, guys. We finally did it. We are only 25-ish days behind schedule on the episode that was supposed to come out July 4th. Trust me when I say, it's my fault. Erin is the most patient woman in the world and has, how many times did we reschedule this, honey?

[0:05:57] EF: Seven.

[0:05:58] MD: Seven?

[0:06:04] EF: Seven times.

[0:06:05] MD: Seven times. But all for really good reasons, like legit Ð

[0:06:11] EF: All for really good reasons.

[0:06:13] MD: The only things in the universe happened. Then today, right before we went to record, while I'm on the phone with Erin, dog bolted out the front door and went through one of the plants, and I ended up having to spend about 30 minutes pulling sticker pickers off of her. I don't know if y'all know, those are the burrowing seeds that get on dogÕs furs and will go down to their skin. We all survived. Oh, she's pissed at me. She nipped at me once, and I popped her on her nose. It wasn't hurtful, but I mean, she's too sassy for her own good. She's like her mother.

Alas, I digress, we made it. If you were waiting on us, my responsibility. I own it and I apologize. Erin wins all the gold stars for patient co-host of the year. Yay, so we're covering episodic care. This is honestly an episode that we created for ourselves, because of things that are going on professionally in our worlds, and we wanting to share what we were learning and growing, and the resources to support it, so that you could grow your evidence-based triangle and help them implement a dynamic approach in your facilities. 

Erin, why don't you tell us how episodic care came up in your world?

[0:07:41] EF: Where I am right now, and I'm sure everybody can relate to difficulties with access, and kids getting seen and weightless being astronomical.

[0:07:55] MD: Yes.

[0:07:59] EF: A lot of the conversation has been around that, because we're not growing speech pathology programs at the rate that patients are needing services, there has to be another solution. One of those is a transition to episodic care, which can look different. There's different interpretations of what that looks like, what an episode looks like, how it is decided that an episode is done. I've talked to people at different facilities that an episode will be six months long. Some places will do three months and see from there, but it's been something that I've had to dive into learning more about, and also having conversations with families about what an episode is, why it's valuable.

Because, yeah, it's great. You can get other kids on your schedule, but then the patients that don't are used to having very consistent weekly services for years and years, it can be very abrupt for them, and it can be scary for them. I like, and we'll talk more about this, but I really like the ownership it puts on caregivers and the clinician to coach the caregiver, because we know that this isn't going to be forever.

You hopefully know that when you start with any family, but I think we've all had those patients that have been on our caseload forever, and that it's like, caregiver and patient don't necessarily know what to do without the clinician, and that's, yeah.

[0:09:49] MD: Yes. Here's our recommendations moving forward. To filter today's episode through your lens, right? We will have patients, that because of their etiology and/or comorbidities, they will always qualify for services, right? However, just because there is a certain diagnosis does not mean that services are warranted at that time, and it is okay to give permission that either the patient has hit a plateau, the patient has reached a level where they are comfortable, whether or not their caregivers are, okay?

At moments like this, I think of my brother-in-law. His diagnosis means that he will always be eligible for services, right? Because he has an IEP. He has a IEP under Part A, IDEA for 21 and older. However, even though he has a diagnosis of autism and intellectual disability, he does not currently receive speech therapy services, because he can joyfully and functionally communicate what he needs, as Erin found out on Father's Day weekend. Yes. Having the boys had an in-depth conversation about Teen Titans Go. It was quite lovely.

[0:11:25] EF: Teen Titans Go, Star Wars and Star Trek, he corrected me on.

[0:11:30] MD: Yes. Oh, he's the man.

[0:11:32] EF: I don't know.

[0:11:33] MD: Yeah, I know. He was worried that you didn't know.

[0:11:36] EF: Yeah. Yeah. Well, and it Ð Kids also deserve to be kids, and just because they have a diagnosis doesn't mean that they don't deserve to Ñ I think too, when you give caregivers permission to take a break, or to just be a caregiver, then it gives them more opportunity to truly understand their child and who they are and just live authentically. Because when we're constantly going to therapy, too, that caregiver is thinking about your goals and what you're working on. Am I carrying this over the way I'm supposed to? Have I done the homework?

Sometimes, just to release that anxiety, Kim Barthol always talks about how when you're working on compliance that creates cortisol, which is what we Ð is elevated when we're stressed. Sometimes when a caregiver is stressed and they're coming to therapy and things aren't going necessarily the way that they pictured, the lack of progress can also be from that stress and that burnout, too, that happens when.

I mean, and I think about it, like I go to therapy, and even making one therapy appointment a month, or two therapy appointments a month is hard for me. The thing that these families go to at least, a lot of them, three appointments a week and these children Ñ I try to put that into perspective sometimes, because it's like, that's a lot.

[0:13:14] MD: Yeah. Yeah. I had a thought, but I'll embed it later. That is, so episodic care in a nutshell and Erin found the most amazing article. It is '5 Strategies to Help Families Act as Speech and Language Coaches' by Susannah Silvia, and it was in the ASHA Leader on June 12, 2019. Excuse me, it's a beautifully written article and she does the best summation that I have found to date. An episodic care model is a model that offers a definitive start and stop date of focus in skilled intervention. She said exactly what Erin said, continuous therapy can cause burnout, okay.

[0:14:07] EF: She does say something very important there. Skilled.

[0:14:11] MD: Skilled.

[0:14:12] EF: Because sometimes, I think we keep kids on our caseload. If the caregiver knows what you're doing, if the caregiver is carrying it over, if you have nothing else skilled, or nuanced to offer the family is what you're doing really skilled? I think, I always think about that, because I'm like, am I Ð oh, I feel like a lot of times we're talking about feeding therapy specifically. You have a kid that's an aspirator and you have them in every week just to watch them drink. Is that really skilled?

[0:14:40] MD: No. No.

[0:14:42] EF: You're monitoring, but we have to empower the caregiver to know how to monitor, so that if they feel something has changed, that they can reach out and contact us. We don't need to build them every week to sit there and watch and see if they cough. If they cough, what are we going to do?

[0:15:02] MD: Document it, but unless it's an overt Ð I mean, I had a coughing incident today, because I flash penetrated, subsequently aspirated a large sip of water in the middle of a Feeding Matter's Zoom call, surrounded by feeding therapists and caregivers. Then I had to flip the camera off while I felt like I was dying trying to eject it, and then went back on totally red-faced. A bunch of the women were looking at me and I was like, ÒYeah. They all know what just happened.Ó

Sitting there watching us eat or drink is not skilled. That, friends, listen to what we're saying. If you're doing that, you're tiptoeing into the shades of gray where if it's not skilled, is it a billable and subsequently reimbursable activity? That could result in if an individual were to make a complaint that that's an ongoing situation, that Ð I mean, that could be a Medicaid fraud issue. There's implications here beyond just learning about a new model, right? It's the, we have to critically assess what it is that we're doing on our day to day. Now, Erin and I, when we first conceptualized this episode, it stemmed from Erin's facility was moving to episodic care on a 12-week cycle. Is that correct?

[0:16:36] EF: Mm-hmm.

[0:16:39] MD: At the university, at our university clinic, we open during the semesters. In between semesters, the university is not available, because the university literally shuts down. Because of the structure of academia, our university clinic has to run on an episodic care model, right? That's just how it is. Which means that we are then charged with educating the caregivers on the purpose of caregiver coaching and why they have to be involved. That also means that we really have to teach our students how to employ not just skilled intervention, but also how to teach a fellow adult. Those two sentences are one very giant long run-on sentence. There's so many steps that go behind on teaching another adult how to learn.

An episodic care model in short is, you have a definitive start in time. It is a skilled service. Then you have a period where therapy does not occur. It doesn't mean that therapy is over and that you never come back to it. You can circle back around the therapy and have a set. We're going to follow up in two weeks. We're going to follow up in a month. We're going to follow up in six weeks. You circle back to, how was the carryover.

I think my favorite piece is that it forces us as clinicians to work on relationship building with the caregiver and guiding the relationship building. I sound like you, Erin. Relationship building between the caregiver and their child.

[0:18:36] EF: Yup. Well, and I'm doing my competencies right now and they talk. There's one article that I really like that talks about parental stress when they're in-patient. One of the biggest parts of the contributor of that is feeling like they don't have control anymore, because they were the primary caretaker of this child. Now you have all these other professionals make decisions taking care of that. I am now the person that sees primarily the inpatient to outpatient kids that we get.

My biggest goal in that is to help the caregiver feel empowered and gain some control back over feeding. Because if they're coming to see me for feeding, there was a shift in that where they need continued support. I think when there's that time limit too, you have to talk more about what those goals are, because you have a specific moment in time. Instead of, I'm going to look at all of these goals I want to work on, and I have as much time as possible, it creates more of a purposeful intentional period of time where you're not just, is this kid going to meet this goal? Okay, we have 12 weeks. Does caregiver feel comfortable?

Okay, we're halfway through. How do you feel that things are going? Should we change how we're doing things? Do you feel comfortable? Okay, we have three weeks left. This is where I've seen the progress. This is what my goal is for when we end. WhatÕs your goal? What's important to you? It creates more opportunity for more of those conversations and then conversations for caregiver to then say, also, where they're feeling, because I think oftentimes, again, that loss of control. They don't always know that they have as much say, or as much of a part of the team as they are.

I've found it does give a lot more opportunity for that collaboration, for that collaborative goal writing, for shifting and adjusting what's working and what's not within the partnership and the relationship that you have with the family that you're working with, because a lot of times, too, I spend working with caregivers on just understanding their kid.

[0:21:02] MD: Meeting the kids. That's huge. How are they? How did Ð Okay, this is a thought. I would love to see a research study. I'm sure this is going to Ð folks, if this upsets you, I apologize in advance, but I would love to see a research study on the prevalence of Òtongue tie diagnosesÓ for breastfeeding infants in worlds, in different countries, where they have federally supported long-term maternity leave.

[0:21:49] EF: Oh, okay. Yes.

[0:21:51] MD: Right? Because I suspect, my hypothesis is that these long-term Ð these countries where they have a long-term maternity leave with a ton of supports, especially the Scandinavian countries, Norway, Sweden, they even Ð

[0:22:09] EF: Time to build attachment with their child.

[0:22:13] MD: Yes.

[0:22:15] EF: Don't give all the things away, Michelle.

[0:22:18] MD: What? These ideas?

[0:22:19] EF: Don't give all the ideas away.

[0:22:22] MD: I don't have really good ideas. But I suspect my hypothesis is that there's a lower prevalence of tongue tie and collet than there are in, oh, no, America, because you have a baby and then you go right back to work, because Ð

[0:22:36] EF: Yeah, two days later.

[0:22:40] MD: Well, I mean, this mommy made it four and six and that felt like a Hail Mary pass right there. Anyway, as I go down trauma lane and leave with that in my head. Okay. Thoughts like that to me tie back into when is episodic care relevant, right? When you're looking at it, what are the settings? Okay, so we can do it at a university. We can do it outpatient. I mean, inpatient, you're obviously there. However, you're really not. If the patient starts, if they have to be sedated, if they have to be intubated, then that period of care stops and it starts again once they're medically stable for services to begin, right?

[0:23:35] EF: Well, and there's a lot more. I feel like, we found a lot more research in the OT and PT world with episodic care.

[0:23:46] MD: This is predicated on, we know how to read our patients, that we recognize when our patients have hit a therapeutic plateau, or when our patients are not medically ready at this time to progress forward, right? As it correlates to a pediatric feeding disorder, if you have a patient whose caregivers want them to progress with new foods. However, they are undergoing major testing, or have a major surgery scheduled. Maybe the caregivers want to try a tapered weaning protocol, but the child is getting ready for cardiac surgery, or I don't know the transplant, because of the conversation that we had earlier.

I would anticipate in that moment in time, if we're going to have work down on our heart, then most likely, there is an increased risk for nerve damage that could result in vocal fluid paralysis. I would wait and hold on that therapy until the patient is deemed medically stable. There's lots of implications for when is episodic care relevant and has everything to do with you and the caregiver being on the same page, reading the patient and recognizing when has a plateau hit, let's pause, circle back around when they're developmentally ready for the next developmental stage, or when they are medically ready, or, oh, I had a thought and then I lost it. When they acquired a new skill that they just need a little bit more time to master it, to say they're doing it in therapy with you, but the caregiver reports are not doing consistently at home, then before you jump into advancing towards the next identifiable feeding skill set, well, wait. Let them accomplish this and feel confident.

Because one of the worst things that we can do is keep throwing the next challenging thing at someone before they feel success. That's also true in all aspects of our lives. That was a lot of thoughts. Okay, where else can you see episodic care being done?

[0:26:10] EF: I mean Ð

[0:26:11] MD: Outpatient, inpatient.

[0:26:13] EF: Outpatient. I mean, it's an episode in-patient, because they're there for how long they're there for. I know home health is tricky in that it depends on where you're getting the funding from. If it's a birth to three, I don't Ð I haven't found that much research in regards to early intervention, episodic care specifically, because I know that the goal is like, let's give them as much intervention as we can while they're young. But still, a lot of that Ð You and I have talked about this too with discharge, because we Ð

You and I tend to discharge kids before other therapists might discharge them. If they're on a good path and the caregiver feels comfortable with the plan, then it's similar to when a kid, a child is put, is given tube feeds. We just take away so much control from the caregiver. It's like, I don't need to be your Ð If I feel like I'm being your babysitter, no, this is too much. Am I really give you new things, or am I just babysitting and watching to make sure you're doing it the right way?

[0:27:25] MD: Yes.

[0:27:26] EF: You know what I mean? If you start to feel like I'm just here, then that's when Ð and it's about trusting your caregivers and trusting yourself. The nice thing about thinking about the episodic care is yes, you might end up having more patience in your brain and that you keep in touch with. Just because they're not getting therapy doesn't mean they can't reach out for consulting. It doesn't mean they can't Ð the thing with episodic care, they're still your patient because they're taking a break. It's not an official discharge. Hey, something happened, I really need to come in for a visit. Okay. LetÕs check it and see how everything's going. Let's problem solve this.

It's not cutting them off and saying, it alleviates that I have to discharge them, or I have to keep them on forever. It gives you a good middle ground of you're still my patient. I'm still going to support you if something happens with a doctor, we can still talk about it. I can still reach out to your physicians and have conversations with them. Right now, we're not getting weekly therapy, because we're giving them time to live and be a family.

[0:28:40] MD: This is how it would look on my home health schedule, right? When I was doing home health and I was doing episodic care and home health, this is how it would look. I would have Ð Honestly, I worked four days a week and I saw four to five patients in four days, because the fifth day was just for podcasting volunteer work and advocacy events, right? I only worked Monday through Thursday. I would have on my case load 20 to 25 patients, right? I wasn't seeing 20 to 25 patients weekly. I was probably only seeing 18 to 20 patients a week.

Then the other patients were either biweekly, or once a month, or I would just call and check in, ÒHey, how are you guys doing? Do we need to go ahead and discharge, or would you like to do a home health visit?Ó By flexing my hours that way, and yes, did it mean I had increased IFSP meetings, because we had to be able to fluctuate the frequency of services, as opposed to only seeing once every six months? Yes. I mean, sometimes my IFSP meetings were once every three months. We were like, ÒHey, this kid's ready. We're going to go back to weekly.Ó Or, ÒHey, this kid still needs to be plateaued, or on biweekly, or once a month because they're still in a plateau, or they're in a holding pattern.Ó

There is a way to build this into your schedule, such that you're meeting the needs of those individuals where they are and still Ð how do I explain this? If you're seeing them once a month and you have four, or five that you're seeing once a month, then you can hold that same hour for those patients and just rotate through, right? There's wise ways to put this into your scheduling, so that you're still providing for your family, which I know that you are. You're still meeting the needs of your patients. There's a way to meet both, right?

[0:30:55] EF: Mm-hmm. I had a thought.

[0:31:06] MD: YÕall, we are recording at the end of the day. Erin was slammed today on Ð you were on what? The transplant floor and GI floor. Is that would floors you were on to?

[0:31:14] EF: Floors in the cardiac floor. My brain hurts a little bit from all the surgeries I learned about today. It's more work, because you're juggling more case management. At the same time, that's our job. Then it becomes, and it also, things are changing. Sometimes when things start to change, it can get really difficult. If more people started to move towards this episodic care model with more consulting, we could advocate more for getting paid for some of that consulting and being able to be able to bill for that. Also, if it helped with Ð

 [0:31:58] MD: Wait, hold that thought. I saw an article. It came across my desk and I'm going to have to go back and find it.

[0:32:04] EF: You either had a really serious idea, or something exploded outside of your house.

[0:32:09] MD: Yeah. I had my oh, my goodness face. There was an email update and it came out from ASHA, because I'm on the Ð I don't know if you guys know this or not, you guys can customize your ASHA listserv, so that certain articles, or certain words trigger and they will send you email updates. There's a new CPT code that comes out next year that actually allows for reimbursement, if you consult with physicians and it's a higher rate. I'm going to have to go back and find it. Because when I read it, I was confused. I didn't know if it was Ð I don't remember if it was, you had to be inpatient, or if it was in the same building, or if it was a phone call incident, or if it was a Zoom meeting. 

I just saw that it came up and I was like, the amount of home health therapists that could get reimbursed for the time that they put forth in consultative services. I'll go back and find that and pull it for the next time. Yes. Okay.

[0:33:16] EF: Yeah. I mean, because when you work in inpatient, a lot of times things, the billing gets bundled together. It's not as much of a Ñ when youÕre in home on paper visit, every phone call.

[0:33:33] MD: Yeah. Depending on the state, oh. That's complicated, for another day. Okay. Tell us about this article that you found and what you loved in it and why it spoke to your soul then.

[0:33:46] EF: Which one? The ASHA one?

[0:33:47] MD: Yeah, because it was so good.

[0:33:49] EF: Well, I really liked that she talked a lot about Ð I mean, the goal was, again, how do we build coaching and how do we work more with caregivers? Which is, how do I say this without being, I don't know. I think it is harder, especially when you start. They always say, you know you really know something when you can teach it to somebody else. If you're not totally comfortable with what you're doing, it's going to be really hard to coach a caregiver to do that, which makes sense.

I do feel like, there's some Ð we also have to be honest and transparent with our caregivers. Yeah, there's a sense of not necessarily feeding, but people will say, fake it till you make it. I look at it as be open about your thought process, because you may not have all the answers. If you talk the caregiver through why you're doing what you're doing, that can help them understand what might work for their child. If you don't know why you're doing, so this is also another thing. If you don't know why you're doing something and you're just doing it, because some other supervisor told you to do it and you canÕt explain that to a caregiver, then that's another checkpoint of, ÒOoh, why am I doing this?Ó

Because caregivers are going to ask questions. The answer is not, this is how someone else did this, or this is how Ð It is really hard. Working with kids is really hard, because you work with them and their caregivers. I find my hardest sessions are my sessions where caregiver and child are not matching up with their expectations, or their sensory systems, or their Ð how I'm connecting with either one of them, because I feel like I'm now having to shift between the session and then also help their relationship. That can be really difficult. Then it poses the ability for you to either demonstrate what you're doing with the child, or to take a step back and try and understand where that's coming from, because you live in the house you grew up in. There's reasons behind why a relationship is the way that it is. That coaching aspect. I don't know. I think I don't love calling it coaching, because it gives this inclination of like, I'm the coach and you're Ð I think itÕs Ð

[0:36:37] MD: It's so much more than that.

[0:36:38] EF: Collaborating is what it is. Yeah.

[0:36:48] MD: The work that I learned from Dr. Burns and the courses that she had me sit through from Dr. Julianna Woods out of Florida, it is so much more of when you're engaged in caregiver coaching, you're almost like the caregiverÕs life guide to helping them navigate a treacherous path that they didn't know was coming. Now they're there. You're asking them probing questions. Not just saying, ÒHey, I need you to throw a rope here and tie it off here. Then you can traverse the bridge this way.Ó It is seeking to understand, do they have the skills to throw a rope, tie a knot? If not, giving them the supports. Sorry, Bear's been watching a lot of Mount Everest shows lately. That's what I went to Ð

[0:37:48] EF: Well, and to not. That's the other thing is, and this is where I get caught, and I have to take a step back is there will be times where I really connect with a child and build a really strong relationship, but it's not anywhere near close to how that caregiver is going to interact with that child. That's when we have to shift what we're doing to better align with that caregiver. There's a balance. Sometimes I will model it for a while, if I know the caregiverÕs eventually going to buy in. Sometimes I have to really go to them to bring them to another spot.

Sometimes that caregiver is not going to budge and that is okay. If you can't reach them, they might need somebody different. I've found there's a couple patient Ð there's families I've worked with where I just Ð my core values and their core values are not aligning. That doesn't mean there's a wrong, and mine are right, it just means that weÕre Ð

[0:38:52] MD: There's a difference.

[0:38:53] EF: ThereÕs a difference.

[0:38:54] MD: That's okay. Okay, so Ð

[0:38:57] EF: I'm going to try my hardest to adjust for them. Sometimes it doesn't always match. I'm going to try my best. As a professional, it's our job to adjust first. Hi, dog.

[0:39:17] MD: Dog says hi. Dog says, ÒI forgive mommy for pulling all the sticker pickers out of me.Ó Okay, so there's a really good website. It's on ASHA. It is asha.org/practice/payer-portal/service-delivery-methods/.

[0:39:39] EF: I love when you do this.

[0:39:41] MD: When I Ð I donÕt know.

[0:39:43] EF: You do know you could just say like, ÒGo to ASHA and search service delivery models.Ó But she's like, ÒWww://Ó

[0:39:52] MD: Okay. Love my middle age show. We had to do that back in the day. Oh, my God. I was thinking of something. Fun fact, y'all, like all things in the universe that conspire against me, we just power through. I have a fourth cousin, cannot make this up, that was born the exact same day as me. Given the exact same maiden name. This was pre good internet. We found out when we were 18 that each other existed, when we both on the same day went to buy a car and get a car loan, the universe, and thought the other person was committing fraud on other parts of Virginia and trying to cancel each other's information.

After numerous trips of driving back and forth to the Social Security Department, because I am middle age, and it was pre-high-speed internet, like readily available everywhere to manage life, we found out that I am four hours older than her, and she got a new Social Security number, and I got to keep the original Social Security number, which worked out really, really well until today, when we went to do my retirement benefits. Because apparently, my fourth cousin is enrolled in Virginia Retirement Benefits under my maiden name, which was her name. The universe.

The long story short of that is there's things that pop up that I still Ð that's how I was taught Erin, www. Anywho. Okay, fun, scary facts. Maybe one day I'll have a retirement plan created in my own name. Who knows? Maybe. Okay, but on this website, everybody's like, ÒAre you sure we're right now, Michelle?Ó Yes. Yes, it really happened. They go through on this website and actually break down potential treatment approaches and individual group treatment, co-treatment of skilled maintenance telepractice consultation, and then targeting IPE and IPP.

I love under the skilled maintenance program, that is exactly what you plug in and create and teach the caregivers during the breaks in episodic care, right? You make sure that they have a strong, robust program and that they know who to call when, and you check in. There's resources in here. What I also liked is that there is a tool and it's called thinking through varied Ð hold on, internet. Thinking Through Varied Service Delivery Models. It's on that same page.

ASHA has created this tool. Say you're totally onboard with doing episodic care and you're trying to pitch this to your higher ups at your private practice, that by transitioning to an episodic care model, you're going to be able to better serve the individuals in your community, right? You're trying to guide your colleagues, or maybe a student, or a younger clinician in how to come to this decision-making process, well, they have a free tool to work through it. This is when you're sitting through a staff meeting, this is something that could be pulled out for to make the staff meeting relevant. Because let's be honest, not all staff meetings are relevant. Sometimes you're like, especially if you work in the public schools, you're like, ÒWhy am I here?Ó This would be a really, really good tool. Oh, oh, we adulted, because we turned this into a doc. They're also in the show notes. Oh.

[0:43:37] EF: We did it.

[0:43:38] MD: Yes. Look at us. Nailed it. Last night, we were like, ÒWe're going to record.Ó I was like, ÒHow about instead we do part one, the research fact finding an organization and then tomorrow night record?Ó That was the seventh and final reschedule. I thought Erin was going to drive to Stanton and whoop me. Okay, so there are those thought points, thought processes. We covered the who. We covered the where, the different settings. We covered the when, and it's the why next, correct? Who, what, where, when, why? Yes. Okay. Where, when, and why, why?

Okay. Here is why. Unfortunately, this therapeutic intervention, this approach has not been incredibly well-researched within the world of speech pathology. If it has, then both of us just completely managed to miss all potential articles, which is really sad. But our colleagues in the OT world, God, we love our OTs, they have put together some great resources. I did find a really good, aphasia resource for adults, but not in the peds world. I know we're asking a big ask. This is what we're advocating for is a complete shift for a lot of us, especially those of us that went to school where everybody gets services one to two times a week.

Also, on that note, if you're Ð the facility that you're working for has a prescriptive model of every child gets services twice a week, or every child gets services once a week, that actually opens your facility and yourself up for potential code of ethics violations. You cannot carte blanche everybody gets the same frequency and duration of services. It is specific and tailored to the individual child, or patient for their level of need, which Ð

[0:45:50] EF: That can mean, okay, we have a standard. We offer everyone a certain number of visits, and then based on your further evaluation, we use less. Maybe we add on a couple. It is hard, especially in big organizations to have as much freedom. But to give some leeway to clinicians to be able to adjust is important.

[0:46:15] MD: Yes, yes. Okay, so the first article we found is Ð Hold on one second. It is opening up. It's called 'Episodic Versus Continuous Care in Outpatient Pediatric Clinics'. It's from the university, is that word, Puget, Puget Sound? P-U-G Ð

[0:46:36] EF: Puget Sound, I think.

[0:46:37] MD: Puget Sound. Somebody somewhere is laughing, because they know exactly how to say this word. Also, Barb, if you're listening, I feel like, I can see your face belly laughing and going like, ÒOh, Michelle.Ó There it is. University of Puget Sound. It was created by Rebecca Newman, Kimberly McGarvey, and Laura Hope. What I love is that this article was actually led by a PhD level researcher, George Tomlin, PhD, OTRL. He's a fellow of the American Occupational Therapy Association. It was a Capstone project. It was published, came out in May of 2016, and it's free open access. Anybody anywhere can access this. 

Ma'am, did you eat the hamster? Erin, if you would like to touch base on who they interviewed and the age ranges of this very quickly, I just need to go make sure that Dr. Bubblebutt lives.

[0:47:54] EF: Okay, let me find it. Let's see. You were really doing so well. Now I'm really having a Ð

[0:47:59] MD: So sorry.

[0:48:01] EF: Now I'm really, you found this one. Guys, just bear with us. Maybe this will be Ð Okay, like she said, it was a Capstone project and they were looking mostly at evidence for children with cerebral palsy. This was with children with orthopedic conditions, or developmental delays. That was their question. Is episodic care as effective as continuous care? Because if we're getting just as much from creating these episodes of care and allotting for better access and allotting for families to take a break and not have to come to therapy all the time, then why are we having them?

Something to note that I found is I think it does breed better attendance when you have episodes of care, because they know they have a certain number of visits. There's less of a, ÒOh, well. If I just cancel this week, I'll come next week.Ó I think that is something important to know, but they did expand some of their research to children with all diagnosis, a diagnosis, but didn't include ASD, which I think probably would just get them into a lot of other articles that maybe they just weren't Ð was less focused, especially from an orthopedic standpoint.

Like they said, a lot of this was for CP, but CP is one of those diagnoses that just has more research, because there was more understanding of cerebral palsy before a lot of other diagnoses.

[0:49:55] MD: There's lots of funding there. Dr. Bubblebutt is alive.

[0:50:00] EF: Why do you thought that she ate Dr. Bubblebutt?

[0:50:02] MD: Yeah. Because she came downstairs literally licking her lips, and I could hear noise upstairs.

[0:50:08] EF: Nice.

[0:50:07] MD: Yeah. We're fine. Also, the universe, it turns out he was completely out of water. This was a good call. Go team. Sorry.

[0:50:15] EF: Great.

[0:50:19] MD: Yay. What I really liked in this article was the depth which they analyzed every single study that they went through. They were very candid. The summation of it was that the therapist can feel confident that scheduling treatment around reasonable real-world constraints will still provide no less effective care for their clients. That was their concluding statement. It was the benefits between regular prescriptive therapy, versus, and by prescriptive, I mean, once a week for X weeks for basically, all time, or episodic care. One did not outweigh the other. They were equal, which is fantastic, because that allows for us to look at creating and scheduling therapy through an entirely new different one.

[0:51:20] EF: Well, and I will say, and you said how they wrote the article. I do think you'll find when you read occupational therapy articles that there's a lot more, what's the right word? They're a little more not liberal with their discussion, but I think their discussion feels a little less technical sometimes.

[0:51:40] MD: Yes. It's not as, and I don't want to say stiff, but it reads more from the perspective of there's less emphasis on the technical research, and it's more readable. It's almost as if there's a conscientious push towards directly embedding it into therapy, if that makes sense.

Okay, is there anything else that you wanted to take away from that article?

[0:52:14] EF: I don't think so. I think it's interesting to think about, okay, because therapists are a finite resource, and I hate to say it that way, but there's only so many of us. Yes, this is a very specific patient population, but it just opens the door to more research on if we're getting the same outcomes from seeing them in shorter spurts of care, then continuously, that I'm going to use my time, too, to see other kids. Because where I get really frustrated is when I have patients on a wait list that have no plan. They have no plan.

Then we have kids that we've been seeing for years that still are obviously in need support, but they have a plan. They have a caregiver that has been coached, and we've worked through a lot of things with. My thought is always, okay, how can we get more patients in to create a good plan, so the caregiver feels comfortable? Because who knows what's going to happen six months from now when they finally get off the waitlist? It's just crazy.

[0:53:25] MD: Sometimes I feel like, our biggest Ð when I read these things, I feel like my biggest takeaway is validation that it's okay to think different.

[0:53:34] EF: Yeah.

[0:53:38] MD: Also, it worries me when I look at the article, the OT article, it makes me feel like our profession is behind the times. That comes out very harsh, right? I feel like, we just have a lot more growth to catch up with. That's okay. We can create safe spaces, but as you said earlier, when we first started, we don't have enough programs to graduate. I mean, we're starving for clinicians and programs. Yeah.

Okay. All right. The next article is actually from an aphasia literature. Right out the gate, I'm going to give this a caveat that this is an adult article. But again, trying to find peds articles on episodic care is in the world of speech pathology is limited. This is called 'Dosage, Intensity, and Frequency of Language Therapy for Aphasia: A Systematic Review-Based, Individual Participant Data Network Meta-Analysis'. Oh, my goodness. It's a very long one. It was published in Stroke. It came out December 1st, 2021. No, I'm sorry. March 22nd, Volume 3, Issue 3. What this Ð

[0:55:13] EF: Www. Just kidding.

[0:55:21] MD: Oh, my God. I love you. Well, okay. What this article goes through Ð

[0:55:25] EF: You forget about Google. You forget about Google.

[0:55:29] MD: I mean, there is some fellow middle age woman on here like, ÒYeah. Thank you, Michelle. Say it slowly. Repeat it twice. Oh, my God. I'm turning into my mother. God help us all. Okay. The question is which one, grandma, my mom, or my stop mom. Probably a little of all the three. Okay, so in this article, they studied data from 959 participants. It was 25 different trials were included. They went through and they looked at the recovery time post stroke. 

Now, let's be honest, some of our pediatric patients have strokes. It could be right at birth. It could be later on. God, our sports injuries, our car accidents, an aneurysm that wasn't known that there was a blood vessel difference, or complications from medical procedures. Bad things can happen, which are horrible to think of as a parent, but we're just going to put joy in the universe and choose hope. That's where I pulled this from, is that if we have the research from our adult aphasia post-stroke survivors and recommendations on rehab intensity, that should hold merit when our pediatric patients have similar, or same etiology.

The conclusion from this article, and I'm going to read it straight. Again, gave you all the fact-finding stuff. The greatest language recovery was associated with frequent functionally tailored receptive expective speech therapy with prescribed home practice at a greater intensity and duration than reports of usual clinical services internationally. These exploratory findings suggest critical therapeutic ranges informing hypothesis testing trials and tailoring of clinical services. In short, the once a week, or twice a week for X period of time did not help these individuals make their optimal gains. It was get in, get in quick after the infarct has occurred, or that the lead has occurred and do your intense training with emphasis on the skilled home program.

To go back to what we talked about a minute ago, under the service delivery models that you can find on ASHA's website, the skilled maintenance program, that making sure that they are intense, that they are tailored, that they meet the patient, or the caregivers needs. As I was reminded, I learned a new word this week from my co-worker, Sarah. Give credit where creditÕs due. Sarah Teeter, she's one of the clinical educators at the university. She taught me a word called therapeutic alliance. Have you heard of this term?

[0:58:32] EF: Yeah.

[0:58:33] MD: Oh, I live in the dark ages over here.

[0:58:36] EF: Where you have been all the time, Michelle?

[0:58:38] MD: I'm not in the cool kidsÕ club. Dang. As I sit here in my soft, pink, striped fuzzy PJs. That's my life story. Anyways, so therapeutic alliance, the way she described it was in the situations where you can't do child-led therapy for whatever reason, her example was a child with a speech sound disorder that's older and that you're working on drills and frequency. I was like, ÒOh, Bear.Ó Or Goose with the spelling stuff, right? She's like, ÒYou develop therapeutic alliance.Ó

They may not be able to lead the duration of the session, but they're picking and choosing their break activity. Excuse me. It's still, they're leading in their own way, but you've created a bond to get buy-in and understand what they want out of the therapy session, which we forget that that's a critical corner of the evidence-based triangle, that research, yes, clinical experiences, yes, but also, the patient caregiver, goals and feedback. That's what makes it.

[0:59:52] EF: Also, I think when you come to therapy every week forever, a number, a number, a number. Every week, you're also coming and not having met all of your goals. That can be very upsetting for caregivers and children. By creating these episodes of care, too, you can create goals that are a little more functional and have immediate success and growth, so that instead of every time I'm coming here, I'm not meeting these goals, we're not getting to where we need to be. Over and over and over and over and over again, it creates opportunity for the caregiver to just Ð and the child just take care of themselves for a little bit, and then to be in a better place mentally to start therapy up again and really invest in it and really be committed, because that would be hard to have to go to therapy every week. Every week I'm hearing what we're not doing, what goal we didn't meet, what our next step needs to be, kind of thing.

[1:01:04] MD: I went through this with Bear, with his RÕs. God bless America. I did not think he would ever get through those freaking Rs and I was ready to chuck R out of the alphabet on behalf of humanity, right? I was like, ÒHe's just done.Ó I remember Angela, Dr. Angela McCloud, if you're listening, we love you. We are not worthy. Angela was like, ÒMichelle, he's four years and five months old. It is not developmentally appropriate.Ó She would pull out the Iowa-Nebraska norms of articulation, go through the sounds that were appropriate, and then say, let's target this goal. Let's target this, blah, blah, blah, when it's developmentally appropriate.

Yes. Thank you, Angela McCloud for sitting me down and reminding me that this is best practice for speech sounds disorders. This is best practice switching to episodic care. It was no longer developmentally appropriate for the boot Bear. It hit a plateau. We're going to circle back around and go back to it. We did. He eventually got the R. To close on a high note, what is your favorite episodic memory story?

[1:02:22] EF: Episodic memory.

[1:02:25] MD: Yeah. Like, I have a little guy that we would plateau and that we would come back to. Every time we came back Ð

[1:02:33] EF: It's a hard one. I just started. I don't know. I do have one kid though, I'm really going to miss, because he calls me doctor and he runs Ð the biggest hug. I tell him I'm not doctor, but he doesn't believe it. He pretends to be sick, so he can come see me. So cute. I think we have a little bit, an anxious, insecure attachment to me, so we're transitioning to another therapist, but I love him so much, but he's a little too attached to me. He calls mom by her first name.

[1:03:07] MD: And you, doctor. I love this.

[1:03:08] EF: ÒDoctor. Doctor, help me.Ó The last session though, he called me Miss Erin. I was like Ð and we don't get a lot of kids that can call us by our names.

[1:03:23] MD: I get Mooshell. Yeah, they call me Mooshell. It is hard. It is hard with that transition in [inaudible 1:03:31]. I'll see you in a couple of little ones. My favorite one was a little girl who did have congenital heart defect and had survived her surgeries. When I started with her, she was in hospice care and did not have a feeding tube. Was probably seven, or eight-months-old. We were working through different plateaus. She was so, so afraid of me, because of scrubs. I would toss on a sweatshirt when I went in, or that's honestly, it's when I started wearing a lot more t-shirts to work, as opposed to scrub tops.

It was hard for me for the mom, because I grew attached to her and how she Ð her parenting style was just, it mentored me in my parenting style. When we would hit a plateau, I would say, ÒOkay, so then let's just work on this one thing and I'll see you in a month,Ó because it's going to take a month, because of her complexity. I got to be with them as they moved through hospice. They graduated into palliative care. Then she discharged to be just a regular little girl. I mean, she's going to need additional heart surgeries later on, but not till we were three or four.

It was really inspirational to see that therapeutic approach worked for the child and the mom, while also hard to let go. Hard to let go. Also, the most amazing early interventionist, because we're like, ÒHey, we got increased services.Ó She's like, ÒAll right, I will make it work. I will see you next week.Ó She would no matter how many other kids are on her case load, this woman would move heaven and earth to be there for this child, so that we can Ð which that is not lost on me. I know it was one of those things where the stars aligned. But yeah.

Okay. Ma'am, you have some exciting news that we need to share. Yes, this one is about PFD, but you have a live presentation coming up in October? October. Tell us where they can find you and what you're covering.

[1:06:00] EF: It's the DIR Conference. ICDL that hosts DIRFloortime. It's all virtual. There's a lot of really great courses and it's over 10 days. IÕm presenting twice. They like to just give a lot of opportunities for people to see different courses. I'll be presenting on play and feeding therapy. Floor time, feeding therapy.

[1:06:25] MD: Amazing. Then folks, I'm actually presenting in September at the Mississippi State Speech Language Hearing Association Conference. I will be in Flowood, Mississippi, which I didn't know was a place, but now I do. Oh, and you know who else is presenting that weekend? Renee. Renee Garrett. She treats adults. If you dibble-dabble and you cross over into adults, Renee will also be there. Come visit myself and Renee in Flowood, Mississippi at the MISHA Conference. I'm doing a talk on how to conduct a PFD eval in the schools. I think this one I have been asked to speak on, but Ð

[1:07:11] EF: Great.

[1:07:11] MD: Yeah.

[1:07:12] EF: ItÕs all good.

[1:07:16] MD: It's there. We'll be there. Right now, I'm just glad that dog didn't eat Dr. Bubblebutt. Dr. Bubblebutt got Ð

[1:07:23] EF: Probably wouldÕve been so sad for Bear. He is done preparing himself. He knows how old they are in human ears.

[1:07:29] MD: Yes. Bear has. This has been a Bear-heavy episode. Yes. He's trying to convince mommy that he needs a chinchilla. I know.

[1:07:38] EF: He'll shock you with a hamster like that. Just kidding.

[1:07:40] MD: I didn't think he would love to.

[1:07:42] EF: Got a fish or something.

[1:07:44] MD: Oh, I've had one of those. The bloody thing froze to death when the power broke during a storm and we were missing a wall. That's a whole conversation for another day. It froze literally in the tank and then came back together. We were living in a hotel, because we had mold living in the house. They gutted the wall and it was February in South Carolina. We had a random deep freeze.

[1:08:08] EF: Dear fish.

[1:08:09] MD: Froze to death, what we thought. But then he came back alive when the heat came on. Because apparently, this fish hibernate or something.

[1:08:17] EF: Yeah.

[1:08:19] MD: I didn't ask for the fish in the first place. This was an in-law decision. Yeah, that was all the other caregivers that are listening that have received an in-law given fish, you're like, ÒYeah.Ó That. Dorothy, Dorothy, the fish, like Elmo's little fish Dorothy. Yeah. That's fun. Okay. All right. That's it, folks. That's what we have. Tri-episodic care. It is a dynamic, wonderful experience. Maybe don't receive an in-law given fish and good luck getting your dogs to not eat your hamsters, and other comedic events. We will see you in September and in October at respective conferences and then come check us both out presenting live at ASHA, and we will see you there. Thanks.

[END OF EPISODE]

[1:09:10] MD: Feeding Matters guides system-wide changes by uniting caregivers, professionals and community partners under the Pediatric Feeding Disorder Alliance. What is this alliance? The alliance is an open access collaborative community, focused on achieving strategic goals within three focus areas; education, advocacy and research.

Who is the Alliance? It's you. The Alliance is open to any person passionate about improving care for children with a pediatric feeding disorder. To date, a 187 professionals, caregivers and partners have joined the alliance. You can join today by visiting the Feeding Matters website at www.feedingmatters.org. Click on PFD Alliance tab and sign up today. Change is possible when we work together.

[OUTRO]

[1:10:02] MD: That's a wrap folks. Once again, thank you for listening to First Bite: Fed, Fun and Functional. I'm your humble, but yet, sassy host, Michelle Dawson, the All-Things PFDs SLP.

This podcast is part of a course offered for continuing education through speechtherapypd.com. Please check out the website if you'd like to learn more about CEU opportunities for this episode, as well as the ones that are archived. As always, remember, feed your mind, feed your soul, be kind and feed those babies.

[END]
FBP 240		Transcript

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