A Google Images search of “speech therapy” produces a flood of images of therapists working directly with a single patient. As a therapist, there’s nothing like working one-on-one with people who are able to make progress by attending to the information we present, dialoguing with us to individualize their care, recalling prior sessions, and having intact executive function skills to complete a home program between sessions. Many other clients, though, may not have these same skills. And facilitating change in a person’s environment via a caregiver really requires an additional skill set.
Recalling the ICF integrative model of functioning and disability, sometimes the most efficient route to impact a client’s activities and life participation is by addressing environmental factors. Environmental factors include the social environment, that is, the people who spend time with the client. Let’s take a look at the why and how of addressing caregiver training in skilled treatment.
1. Strong predictors of nursing facility placement = caregiver distress, functional decline of the patient, and physical strain
Strategies that work and caregiver confidence in implementing them lead to less caregiver distress. Higher quality of care delivered by caregivers helps maintain patients’ function in their environment longer, avoiding nursing home placement as long as possible. It’s a win-win.
2. Caregiver distress puts the caregiver’s health at risk
Caregivers of people with dementia are at increased risk of depression, lower quality of life, poorer health, and increased mortality. Spouses of people with dementia have been shown to exhibit poorer health in areas such as sleep quality, nutrition, activity, stress hormones, and cognition. Setting aside the third-party payment system for a moment – billing practices and that a plan of treatment is in the name of the patient – our services impact more than just the patient’s health. There is a public health component to skilled therapy services that transcends the individual patient.
3. It’s all about function…
So, we know why we should provide caregiver intervention. How do we ensure that our treatment is reimbursable? According to Medicare, caregiver training may be included in billable treatment so long as it directly impacts the patient’s performance of functional tasks, ADLs, and/or IADLs. Clear and objective baselining is essential. What personally meaningful activities could the patient not participate in prior to caregiver training? What activities required extensive assistance from their caregiver prior to caregiver training? How does this compare to the activities and assistance required after caregiver training? Outcomes measures such as ASHA NOMS can capture changes in function based on the type and amount of caregiver cueing.
4. …and skill
Medicare considers therapy a skilled – and reimbursable – service only when the therapist definitively brings expertise and skills to the table that other team members do not. Some strategies, such as limiting the number of conversation partners, talking about the here and now, and using a daily events calendar may be perceived as simple by SLPs. And many caregivers are fully capable of implementing strategies once trained. But if such strategies are not already being used, and result in objective functional improvement when used, training such strategies is a skilled service. A corollary is that even though these strategies seem simple, making systemic behavior change does not happen overnight. Therapy is the time and place where caregivers can practice new behaviors and problem-solve in dialogue with the therapist to help make these new behaviors a habit.
Part of the skillset required of the therapist in this triadic treatment arrangement is to systematically assess the effect of the caregiver’s new behaviors on the patient’s function. This may be relatively straightforward, for example, if the target is using multiple-choice questions and tracking the patient’s ability to formulate a meaningful response. What may be more challenging is indirect training such as stress reduction for the caregiver. And yet, the evidence shows that lower caregiver distress directly impacts outcomes such as nursing home placement. In this case, skilled documentation might: a) cite the literature reporting this outcome, and b) demonstrate the change in caregiver distress as a result of training stress reduction strategies via a caregiver questionnaire, quality of life scale, or similar.
5. Form a supportive practice community to enhance each other’s skills
In one study, occupational therapists implementing a dementia caregiver training program reported no difficulty introducing the program, identifying caregiver concerns, or educating about stress, but they did report difficulty using problem-solving with caregivers. Therapists may have gotten through graduate education with minimal experience of providing significant caregiver training. Chances are, whatever skill you are struggling with, others have, too. There are many possibilities: perhaps dedicate 5-10 minutes of a staff meeting to consulting with colleagues, post in online professional forums, send one team member to a continuing education course addressing the identified need; if using a specific program, email the developer and request guidance.
Gitlin, L. N., Jacobs, M., & Earland, T. V. (2010). Translation of a dementia caregiver intervention for delivery in homecare as a reimbursable Medicare service: Outcomes and lessons learned. The Gerontologist, 50(6), 847-854.
Spillman, B. C., & Long, S. K. (2009). Does high caregiver stress predict nursing home entry? Inquiry: A Journal of Medical Care Organization, Provision and Financing, 46, 140-161.
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