38 Australasian Journal on Ageing, Vol 24 No 1 March 2005, Innovations in Aged Care 38 –40

Blackwell Publishing, Ltd.Innovations in Aged CareSpeech pathology aged care outreach service

Development of a self-sustaining speech pathology service for residents in rural aged care facilities

Rachel PayneThe Collaborative Health Education Research Centre, St Vincent’s Hospital, Lismore, New South Wales, Australia

John StevensSchool of Nursing, Southern Cross University, Lismore, New South Wales, Australia

Objective: The literature suggests that approximately 90% of residents in aged care facilities have communication difficulties and between 40 and 60% of residents experience dysphasia. The ability of residents to attend outpatient clinics or private consultation, especially in a rural setting, is severely restricted. In an attempt to address this service gap a speech pathology service for residents in rural aged care facilities was developed and trialed over a 12-month period. Method: Thirty aged care facilities in the Northern Rivers Area of New South Wales (NSW) agreed to participate in the trial.Results and Conclusion: An analysis of the first 9 months of data collected showed 331 resident consultations, 94 general practitioner (GP) consultations, and 111 education sessions showed that the quality of life of residents was greatly improved. As well, the skills, knowledge and the overall provision of service provided by GPs, nursing and allied health staff to residents of aged care facilities was greatly enhanced. The speech pathology service also proved to be financially self-sustainable and was able to generate income for: (i) GPs through improved access to Enhanced Primary Care (EPC) funding; and (ii) aged care facilities through significant movements within the Resident Classification Scale.

Key words: aged care facility residents, model of service, service provision, speech pathology.

IntroductionAccessing speech pathologists in rural areas is often difficult,especially for older people. The problem is compounded inrural aged care facilities (ACFs) where communication andswallowing difficulties are prevalent and the ability of residentsto attend outpatient clinics or private consultation is severelyrestricted.

The literature suggests that approximately 90% of residents inACFs have communication difficulties [1] and between 40 and60% of residents experience dysphasia [2–3].

A needs analysis conducted by a team of speech pathologistsworking in the Northern Rivers region of New South Wales(NSW), Australia, successfully surveyed approximately one-third of the 32 ACFs in the region. The findings confirmed theliterature by identifying that approximately 85% of residentsin the Northern Rivers of NSW had health related diagnosesthat indicated significant potential effects on communicationand swallowing. Of these residents, 60% were identified by staffto actually experience communication difficulties and 22% weredysphasic.

The needs analysis revealed a shortage of speech pathologyservices for residents of ACFs within the Northern Rivers areaof NSW. A combined total for all facilities of 6 h of speechpathology was recorded for the 12-month period prior to thesurvey. This compared to an average for each facility of 90 hof physiotherapy and 92 h of occupational therapy.

The needs analysis also found that unresolved funding issuesbetween Commonwealth and State Governments resulted inresidents having only limited access to services funded by theNSW Department of Health, while no Commonwealth fundedspeech pathology services existed. The analysis also found thatthere was an insufficient number of private speech pathologiststo meet the needs of ACFs, even if they could afford the service.The few residents who were able to access services as out-patients needed to be accompanied to the clinics by at least onestaff member of the ACF. This resource implication severelyrestricted, if not totally prevented, access to the limited out-patient services.

In order to address the findings of the needs analysis, theCollaborative Health Education Research Centre (CHERC)at St. Vincent’s Hospital (SVH), Lismore and the NorthernRivers Division of General Practice collaborated on develop-ing and trialing a speech pathology service specifically foruse by ACFs and general practitioners (GPs) to improve thewell-being of older people in the region. The aims of the servicewere to:

1. Improve access to speech pathology services for residentsin ACFs.

2. Improve the knowledge and management of swallowingand communication disorders by facility staff to improvethe quality of care for residents.

3. Improve collaboration between GPs and speech pathologiststo meet the care needs of patients in ACFs and to provideholistic case management.

4. Establish a speech pathology service which could be effec-tive and financially self-sustaining into the future.

Correspondence to: Dr John Stevens, Southern Cross University. Email: jstevens@scu.edu.au

S p e e c h p a t h o l o g y a g e d c a r e o u t r e a c h s e r v i c e

Australasian Journal on Ageing, Vol 24 No 1 March 2005, Innovations in Aged Care 38 –40 39

Service modelA speech pathologist was employed by CHERC, SVH to developand trial the speech pathology aged care outreach service. Aservice package was developed for, and offered to, all 32 ACFsin the region. The service was designed to provide individual-ised packages for each of the ACFs who participated in thetrial. The services offered included: regular and systematicassessment therapy and intervention on an ongoing basis forresidents; care planning and case conferencing with care staffand GPs; and education, training and professional support forcare staff.

A concurrent aim of the service was to provide local GPs withaccess to speech pathology services for their older clients, espe-cially those who were residents in ACFs. The service thereforewas also intended to: improve GP awareness of speech patho-logy needs in the community; encourage GPs to use case con-ferencing among care teams of patients, especially residentsin ACFs; and to provide GPs with a referral point for theirpatients requiring speech pathology consultation.

Service to the GPs during the trial occurred in the followingways: (i) case conferences resulting in access to EPC funding(n = 6); (ii) care plan development consultations (n = 9); sevencommunity based clients seen on the referral of GPs (n = 7);direct consultations with GPs regarding their clients in ACFs(n = 94).

Funding modelIn order for the service to be sustained beyond the trial perioda collaborative model of funding was established. All facilitiesparticipating in the trial were required to contribute financiallyto establish and maintain this non-profit service. Contributionswere calculated based on the number of beds per facility andthe projected costs of running the service for a 12-monthperiod. It was anticipated that the cost of the contributioncould be offset by increased income generated by changes thatthe service would make to the Resident Classification Scale(RCS) scores of the residents receiving speech therapy. TheRCS is the classification scale used in Australian ACFs to deter-mine the level of care needs and thus the daily income providedby Commonwealth Government to sustain each resident. Thepotential success of the funding model was to be largelydependent on as smaller a cost per facility as possible. Thisthen depended on the participation of the majority of the 32 ofthe ACFs in the region.

Trial outcomesThirty of the invited 32 ACFs agreed to participate in the trial.At the completion of the trial the following outcomes wereobserved for the service and funding models.

Service model outcomes

Resident consultationsThis evaluation was based on the data obtained for the first 9months of the trial. In the first 9 months of the trial, 331 residents

were assessed and/or treated by the speech pathologist.The residents’ primary diagnoses can be seen in Table 1. Themain reasons for consultation included: 297 for dysphasia;119 for communication difficulties; and 99 for oral hygieneconcerns (some residents had more than one problem seento). None of these residents were physically capable ofattending an outpatient service by themselves, nor were anyof the participating facilities in a financial position to be ableto provide the appropriate resources to support their residentsin this pursuit.

Most of the residents who were referred to the speech pathologyservice had comorbid conditions. These comorbidities includedischaemic heart disease, schizophrenia, bipolar disease, depres-sion, anxiety disorders, neuralgia, subcortical degeneration,oesophagitis, oesophageal dismotility, Jorgren’s syndrome,tracheitis, chronic alcoholism, chronic and recurring chestinfections, cricopharyngeal dysfunction, hypertension, chronicobstructive airways disease (COAD), chronic airways limita-tions (CAL), cleft palate, or cerebral palsy.

Education outcomesOne hundred and eleven education sessions were provided tothe staff of the ACFs. Sessions included interventions for com-munication difficulties, dysphagia management and oral hygiene.

Staff at facilities evaluated each of these sessions. Analysis ofthe evaluations and verbal feedback revealed four main areasof improvement directly attributable to the education sessions.

Staff reported that they perceived there was an improvedmanagement of people with swallowing difficulties. This wassupported by further investigation which revealed that:

• Previously neglected resident specific diet modificationswere being implemented.

• Improved feeding techniques could be demonstrated by staff.• Improved compliance and understanding of kitchen

staff in modification of meals as specified by the speechpathologist.

• Improved awareness and understanding of dysphagiaresulting in improved identification and management ofthe disorder. This resulted in the development of flexibledysphagia management plans through ongoing diet reviewsand assessments, as well as the reintroduction of oral dietsfor residents who were previously nil by mouth.

Table 1: Primary diagnoses of participants

Diagnosis† No.

Cerebrovascular accident 115Dementia 75Other diagnoses 48Parkinson’s disease 39Respiratory disorders 27Other progressive neuro disorders 14Developmentally disabled 14Mental health disorders 10Head injury 7

†Some residents had more than one diagnosis.

P a y n e R , S t e v e n s J

40 Australasian Journal on Ageing, Vol 24 No 1 March 2005, Innovations in Aged Care 38 –40

Care managers reported, and it was also observed by the authors,that people with communication difficulties were providedwith greater opportunity for rehabilitation as staff were taughtto deliver specific therapy programs for people with dysphasia,dysarthria, dyspraxia and cerebrovascular accident (CVA), aswell as how to use communication aids. By the end of the trialstaff reported that they were still regularly using and improvingthese skills in their care of residents.

In each of the 30 facilities involved in the trial there was animproved oral care program for residents. Staff in each facilityreported that they had an improved understanding of theimportance of oral hygiene as it related to speech pathologyand its role in reducing oral and chest infections. Staff alsoreported that as a result of the education provided by theservice that more time and cost-effective methods of achievinggood oral hygiene had been implemented

Care managers reported improvements in the systematicmanagement of residents with speech therapy needs. They alsounanimously noted an organisational wide shift among theirstaff to placing greater emphasis on prevention and early inter-vention, particularly regarding residents with dysphasia.

Funding model outcomesThe income generated by the collaborative funding modelproved to be sufficient to allow the service to be financially self-sustaining within a non-profit organisation. This was importantfor the sustainability of the service; because so many facilitiesparticipated, the cost per facility for the 12-month trial wasrelatively small, ranging between $2000 and less than $7000per facility depending on bed numbers. In addition, all facilitiesgenerated an increase in their income from the RCS as a resultof adopting the service.

In total there were RCS changes in 75% of residents who wereseen. Of those residents who’s RCS changed as a result of theservice, the average increase was 4.9 points. In many cases theRCS changes were sufficient to result in an increase in Com-monwealth income for the resident being seen. It was calcu-lated that each facility increased its RCS revenue by more thantheir contribution to the service as a direct outcome of thespeech pathology service assessments and interventions. Onefacility increased its return by more than five times its originalcontribution.

The GPs who referred to the speech pathology service reportedpositively on the outcomes of their patients from each referral.They also acknowledged that the service had extended their

scope of practice to an area that had previously been neglectedbecause of an absence of resources. All who participatedreported being able to, for the first time, access EPC funding asresult of having a process that allowed them, without leavingtheir practice, to undertake much needed care planning forolder people in the community.

ConclusionsThe Speech Pathology Aged Care Outreach Service trial hasshown that the service has a viable future. The service is ableto consult among a cohort of people for whom services for themajority were previously unavailable and/or inaccessible. Thetrial has shown that the quality and most probably the quan-tity of life of residents has been improved by this service due todirect intervention by the speech pathologist. As well, overallcare has been improved through improved involvement of,and communication with, GPs and the increase in knowledgeof carers resulting from the education program provided aspart of the service. GPs within the region also now have, for thefirst time, a systematic referral option for speech pathologyservices for their older patients in residential and communitysettings.

The trial showed that the funding model developed wassuccessful. The cost of the service is economically affordableby most ACFs, so long as large numbers participate and con-tribute to the service. In all cases the contributions made byACFs were offset by increases in Commonwealth income dueto changes in the RCS scores of residents who use the service.This service will continue to operate and develop in the NorthernRivers region of NSW.

AcknowledgementsThe authors acknowledge the support of The Northern RiversDivision of General Practitioners, The Collaborative HealthEducation Research Centre, St Vincent’s Hospital, Lismore andThe School of Nursing and Health Care Practices, SouthernCross University, Lismore.

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