Why are CEUs so expensive?

Why are CEUs so expensive

Let’s talk about money. (At least we’re not at the dinner table, okay?)

There have been several posts talking about the costs of apps, which are becoming a much more popular tool to use in therapy. Since many therapists pay out of pocket for the apps we use in therapy, we’re often looking for the best deal (free if possible). However, there’s no such thing as a “free” app, because apps are complex and time intensive to create.

I noticed a similar conversation happening around CEUs. In forums I see therapists looking for the best deals on CEUs, at times having little regard to the quality of the continuing education. These comments are saddening, because I believe our code of ethics requires continuing education, so we become better therapists. Our clinical competency is an ethical dilemma we seldom discuss.

I sent out a survey through my newsletter in September to glean information about people’s thoughts on CEUs. One of the questions I asked is how much you would value a one-hour webinar with CEUs provided from our national associations. The answers I received were not surprising based on the conversations I’ve seen on social media regarding CEUs. Many respondents valued one-hour of continuing education at $20 or less with several people stating the value was zero dollars. Which really begs the questions, why are CEUs so expensive? and why/how do we form our value assessments of CEUs?

CEUs are expensive to provide

There is time and cost associated with providing CEUs. I would like to provide you with three reasons you may have not considered regarding the cost of providing CEUs.

First, becoming an approved CEU provider with the national associations is expensive.

Whenever I have spoken to a therapist and shared this information, the reaction has been the same, “Oh wow, I had no idea!”

This information has been updated based on the comment below: To become an ASHA CEU provider, the provider would have to pay several fees, including an $825 application fee and $550 annual fee. Let’s play those numbers out in an example:
If the CEU provider offers courses at $50 each, they will need 27.5 people to register in order to break even for the application fee and annual fee. In subsequent years, providers won’t need to pay the application fee (however, renewal fees may apply later).

To offer a first course as an AOTA CEU provider, the fees are similar. Application fee is $600 and annual fee varies from $425-1025 based on number of participants each year. For a new CEU provider, the fee would probably be $425. There are no additional fees per course. So in order to break even during the first year the CEU provider would need 20.5 people to register at $50 each.

APTA is structured differently, as APTA does not approve continuing education providers or courses. APTA is different in yet another way; they don’t license or certify PTs or PTAs either. State licensure boards hold the responsibility to license PTs and PTAs and manage competency/CE requirements. In my state there is not an approval process for CEU providers that charges providers money; however, there is a set of criteria CEU opportunities must meet.

It costs money to produce continuing education

Marketing is expensive. Marketing can be done via association advertisements or purchasing lists for direct mail (that’s how all those CEU fliers end up in your mailbox). Check out some of the fees associated with advertising through the associations or purchasing direct mail lists:

  • ASHA charges 21 cents per a name with a minimum of 1000 names per order. The costs for a minimum order would be $210, which means 4.2 people will need to register just to break even for this method of advertising. That doesn’t include the costs of producing and printing direct mail or postage.
  • To advertise in the ASHA Leader with a half page horizontal ad, the cost is $3,640 for one month (or $2,910 if you advertise every month for 12 months). Looking again at our example of $50 per course, 72.8 people who need to register in order to break even for one advertisement.
  • AOTA charges 12.5 cents plus $30 processing fee for mailing lists. Purchasing 1000 names would be $155, which means 3.1 would need to register at $50 each to break even.
  • AOTA’s OT Practice magazine charges $2209 for a half page horizontal ad (or $1876 monthly for 12 months). To cover the cost of advertising 44.18 participants would need to register at $50 each.
  • To order 1000 names from APTA it costs $239 plus a $25 processing fee, which means 5.28 people must register at $50 to break even.
  • To purchase a half page horizontal ad in PT in Motion is costs $3,310 (or $2,315 monthly for 12 months), which is equivalent to a break even point of 66.2 registrants at $50 each.

So why don’t CEU providers market via social media? They do, and it’s not free either. It costs money to promote ads via Facebook, Twitter, and other social media platforms. Someone’s time and energy goes is spent to create ads and determine how to effectively distribute them. Even monthly newsletters costs money. Gray Matter Therapy pays a fee each month to distribute the newsletter.

CEU providers are often big participants in continuing education themselves, whether that be through reading recent journal articles (which have their own fees associated), purchasing books on the topic, or attending conventions, conferences, and other CE events.

How much should CEU providers get paid?

Many people have spent years becoming an expert in a particular area and through continuing education events, share their expertise with you. They do it because they love the topic and have a passion for education and patients.

But they also do it for money. Education is a part of their job. If they didn’t spend time educating, they could spend time using their talents in another way that would make money.

So just how much should a CEU provider make? Is it fair for an instructor to charge $50 a person for an hour CEU event with 25 attendees? That means they are making $1259 an hour, right? Not quite. There is a lot of time, preparation, marketing, and other fees associated with providing continuing education.

Given this information, how do you think we could foster a lifestyle of continuing education that is both cost effective for participants and values the presenters’ time and expertise?

Good news about medications for dementia


Let me just state my bias up front. In my personal life, I avoid taking medications. Rather than take pain reliever for a headache, I drink water. The headache is likely due to dehydration (which is common at high altitude) or sinus distress (and water thins mucous being produced). I avoid medications, but I am not anti-medications. In fact, I take a medication every day and will likely for the rest of my life, because my body requires it. Personally, I believe medications aren’t often necessary, especially as the first intervention.

As a speech-language pathologist, it is not within my scope of practice to give recommendations regarding medications. However, it is within my scope of practice to understand how medications effect the body, especially when there may be side effects impacting cognition or swallowing.

Medications but no therapy?

One of the things I have found quite concerning is meeting a new patient admitted a skilled nursing facility and seeing the list of medications they are on. They may be on a cholinesterase inhibitor and antipsychotic medications for dementia, but they have never participated in any therapy (speech-language pathology, occupational therapy, or neuropsychology). This is concerning, because there are so many benefits to therapy throughout the course of dementia.

In the earlier stages, therapists develop individualized compensatory strategies and routines for patients to help their maintain their independence as long as possible. In the middle to late stages of dementia, therapists work on changing the environment to increase a person’s independence and quality of life. These interventions don’t cure dementia (but neither do any of the current medications on the market); however, they are individualized to help improve quality of life, independence, and safety without side effects.

Antipsychotic medication effects in the elderly

Antipsychotic medications are not without side effects. Common side effects of antipsychotics in the elderly include [1]:

  • anticholinergic reactions
  • parkinsonian events
  • tardive dyskinesia
  • orthostatic hypotension
  • cardiac conduction disturbances
  • reduced bone mineral density
  • sedation
  • cognitive slowing

We rightfully spend great time and energy on fall prevention efforts in the skilled nursing facility setting. How many of those antipsychotic side effects would contribute to an increased risk for falls? Most of them. Besides falls, in people with dementia sedation and cognitive slowing would complicate matters. Yet, these are very common side effects.

CMS sets goal to move away from antipsychotics

Given my stance on medication, especially in the treatment of dementia, I was very pleased to see the this press release from the Centers for Medicare & Medicaid Services [2]. The press release states the goal CMS set to reduce use of antipsychotic medications in nursing homes by 25% by the end of 2015 and 30% by the end of 2016. This is excellent news.

Want even better news? Patrick Conway, MD and CMS chief medical officer said, “In partnership with key stakeholders, we have set ambitious goals to reduce use of antipsychotics because there are – for many people with dementia – behavioral and other approaches to provide this care more effectively and safely.” (emphasis mine).

As an advocate for person-centered healthcare, Dr. Conway’s words make my heart happy. He said, “Ultimately, nursing homes should re-think their approach to dementia care, reconnect with the person and their families, and use a comprehensive team-based approach to provide care.”

Way to go CMS! Now let’s chat about how CMS reimburses for these therapy services that can achieve excellent results without the side effects of antipsychotic medications…


  1. Masand, P.S. (2000). Side effects of antipsychotics in the elderly. Journal of Clinical Psychiatry, 60(8), 43-49.
  2. Centers for Medicare & Medicaid Services. National Partnership to Improve Dementia Care Exceeds Goal to Reduce Use of Antipsychotic Medications in Nursing Homes: CMS Announces New Goal. Newsroom Center. CMS.gov, 19 Sept. 2014. Web. 19 Sept. 2014.

Perceptions of SLPs & Memory Aids in the SNF setting

SLP perceptions

This blog post is a part of Research Tuesday. I read “Perceptions of Speech-Language Pathologists Linked to Evidence-Based Practice Use in Skilled Nursing Facilities”.

The article recognized several barriers to implementing evidence-based practice (EBP) such as:

  • Lack of high quality evidence
  • Insufficient time to study evidence
  • Lack of clinician training to implement EBP
  • Negative workplace cultures
  • Clinician and leadership perceptions of evidence

The article also reviews some suggestions for resolving barriers to implement EBP. (See the article for these details.)

Non-electrical external memory aids are considered one of the most effective interventions for people with dementia. The non-electrical external memory aids can improve communication while reducing behavior challenges. They include things such as visual schedules and memory wallets.

This study looked at the following questions:

  1. Do SLPs and rehab directors have different perceptions of non-electronic external memory aid use for people with dementia?
  2. Do SLPs and rehab directors perceive the SNF organizational context differently?
  3. Is the perception of non-electronic external memory aids consistent with the use of non-electronic external memory aids?
  4. How do SLPs describe the evidence related to non-external memory aid use?

To answer these questions the author created a survey that was completed by SLPs and rehab directors in the SNF setting. In addition, SLPs answered questions specific to non-electronic external memory aids and SLPs and rehab directors completed the Organizational Readiness to Change Assessment (evidence and context scales).

Answers to the research questions:

  1. No significant difference between SLPs and rehab director’s perceptions of non-electronic external memory aid use for people with dementia was identified.
  2. Rehab directors perceived the organizational context more positively than SLPs for the implementation of non-electronic external memory aids. SLPs identified the following barriers to implementation: lack of staff, physical materials, and time.
  3. 45.89% of SLPs reported using non-electronic external memory aids with patients with dementia in the last 6 months.
  4. Most SLPs reported the EBP for non-electronic external memory aids was positive and relevant.

Overall it was seen that clinician perceptions and organizational variable are important factors in whether non-electronic external memory aids are used as a tool for people with dementia.

It is interesting to read a study in which the participants of the study are of a category that you belong to (SLPs in the SNF setting). I am really interested in reading future research looking at the use of memory books in the SNF setting. It is not often that I read research that directly pertains to the SNF setting. It seems much of the research in our field is focused on outpatient therapy.

You can follow the first author of the study on Twitter.

Douglas, N.F., Hinckley, J.J., Haley, W.E., Andel, R., Chisolm, T.H., & Eddins, A.C. (2014). Perceptions of Speech-Language Pathologists Linked to Evidence-Based Practice Use in Skilled Nursing Facilities. American Journal of Speech Language Pathology, doi: 10.1044/2014_AJSLP-13-0139.

Vocal changes during the normal aging process

Mandys Voice Post
Earlier this week, I wrote about our ethical obligation to clinical competence. I mentioned that one area I lack competence is voice therapy. I am thankful to be in a situation where I refer voice patients to my colleague, Mandy Politziner who is an SLP and vocalogist. I asked her to lay some groundwork for understanding normal aging in terms of voice in the blog post today. Thanks Mandy!

Typically after the age of 60, men and women’s voices begin to change. For those of us who work with elders, we know elders’ voices do not sound like our own. Buy why? What exactly is happening to the voices of our elders? The following are examples of changes that can occur in our voices as we age.


Typically beginning in the sixth decade, laryngeal tissues begin to atrophy, or waste away. The vocal folds generally atrophy towards the lateral direction, which results in vocal fold bowing, in which a gap forms between the vocal folds. Atrophy may also cause the structure of the tissue itself to change. Parallel strands of muscle fiber may become fibrous, or criss-cross in shape. This change in shape of fibers may cause irregularities in the mucosal wave of the vocal folds.

A clinician may hear weakness, soft volume and/or breathiness with atrophy, as well as a decreased pitch range.

Neural cell changes

Another change that inevitably happens to many areas of the body with aging is that the neural cells may not function optimally like they used to. Whether through degeneration or malfunction of neural input, the result may be a change in muscle tone of the larynx, and a change in regularity of muscle contraction.

With malfunctioning of the neural cells, a clinician may hear that distinctive “wobble” in the voice that we associate with old age, as well as weakness in the voice.

Laryngeal ossification

Laryngeal ossification, in which cartilage changes to bone, typically starts at the age of 30 and slowly increases until around our 80’s. The good news is that this hardening of the structures can lead to greater stability in the voice, as the voice has somewhat of an anchor for the ever-changing movements in the larynx. The bad news is that ossification can lead to lack of agility of the voice. This is particularly stressful to our elders who sing. For those of our elders who sing in their local community or religious choirs, this lack of agility can be particularly upsetting to them.

With laryngeal ossification, a clinician may hear difficulty with a patient’s ability to change pitches quickly and freely.


Just as someone can get arthritis in their fingers or toes, the elderly can get arthritis in the joints of the larynx. Due to inflammation, these joints may become limited in their movement, affecting adduction, abduction, and cricothyroid movement.
With laryngeal arthritis, a clinician may hear limited pitch range.


Personally, I have heard more roughness in my patients’ voices than weakness. Roughness may be caused by edema, which can also manifest as we age. Edema is swelling caused by excess fluid in the vocal folds. The excess fluid can disrupt the mucosal wave pattern.

With edema, a clinician may hear vocal roughness.

Hormonal changes

Hormonal changes may be the contributing factor to change in fundamental frequency as we age. The male voice gets higher with age, and the female voice gets lower, possibly due to decreasing testosterone and estrogen levels. After men and women are well into their 80’s, their voices may be indistinguishable from each other.

Potentially due to hormonal changes with aging, the clinician may hear a low voice in a female (below 200 Hz) and a high voice in a male (above 150 Hz).

These are examples of typical changes of the aging voice. Of course, certain populations can beat the odds and maintain a healthy voice as they age, such as those who are trained singers or speakers.

It is important to note that this list contains examples of occurrences in the normal aging process, and does not rule out that your patient does not have an actual voice disorder. If you or your patient suspects a voice disorder, send your patient for an otolaryngologist evaluation

Titze, I.R. (2000). Principles of Voice Production (2nd printing). Iowa City, IA: National Center for Voice and Speech.

Guest blogger bio:
Mandy Politziner, MS, CCC-SLP, is a speech-language pathologist in Boulder, Colorado. She recently graduated from the Summer Vocology Institute at the National Center for Voice and Speech under the direction of Dr. Ingo Titze. Mandy has a BFA in musical theatre from the University of Michigan, and she enjoys combining her arts and science backgrounds as she works with her clients at her skilled nursing facility.

Another ethical dilemma: Clinical competency

SNF Ethics

The ASHA Code of Ethics states:

  • “Individuals shall provide all services competently. Individuals shall use every resource, including referral when appropriate, to ensure that high-quality service is provided.”
  • “Individuals shall honor their responsibility to achieve and maintain the highest level of professional competence and performance.”
  • “Individuals shall engage in only those aspects of the professions that are within their scope of their professional practice and competence, considering their level of education, training, and experience.”
  • “Individuals shall engage in lifelong learning to maintain and enhance professional competence and performance.”

APTA Code of Ethics states:

  • “Physical therapists shall demonstrate independent and objective professional judgment in the patient’s/client’s best interest in all practice settings.”
  • “Physical therapists shall make judgments within their scope of practice and level of expertise and shall communicate with, collaborate with, or refer to peers or other health care professionals when necessary.”
  • “Physical therapists shall achieve and maintain professional competence.”
  • “Physical therapists shall take responsibility for their professional development based on critical self-assessment and reflection on changes in physical therapist practice, education, health care delivery, and technology.”
  • “Physical therapists shall cultivate practice environments that support professional development, lifelong learning, and excellence.”

AOTA Code of Ethics states:
Occupational therapy personnel shall

  • “Provide occupational therapy services that are within each practitioner’s level of competence and scope of practice (e.g. qualifications, experience, the law).”
  • “Take responsible steps (e.g. continuing education, research, supervision, training) and use careful judgment to ensure their own competence and weigh potential for client harm when generally recognized standards do not exist in emerging technology or areas of practice.”
  • “Refer to other health care specialists solely on the basis of the needs of the client.”
  • “Take responsibility for maintaining high standards and continuing competence in practice, education, and research by participating in professional development and educational activities to improve and update knowledge and skills.”

While we are looking at the ethical dilemmas in the prevailing model of healthcare and how it impacts our patients, we should also take some time to look at our clinical skill. We are bound by our code of ethics (and likely your state licensure) to continually improve clinical skill and practice only in areas where we are competent. Improving our clinical skill and competence is great way improve elder care.

Social media is good, but not great

Social media is a good thing, but I am concerned that it may be the easy way to solve some of our clinical dilemmas. It is almost too easy to hop on social media and ask a clinical question. But are you getting a clinical answer? Sometimes yes. Other times you are getting people’s experiences and opinions.

Experience is really important. In fact, when we look at great therapy we are considering two types of experience – patient and clinician – along with evidence based practice. What’s missing on social media is other people don’t know you (and your skills) and your patient (and their specific presentation).

So we really need to make sure that we are becoming better clinicians. We need to feel competent and confident in our services. Our patients deserve the best.

What if you aren’t competent?

No sweat. I’m not competent to treat every SLP patient either. If you are referred a new patient that you aren’t competent to treat, you can do a few things:

  • Refer them to another therapist that is competent in that specific area.
  • Contact a therapist (or clinical specialist) in your region (employed by the same company) and negotiate to have that person coach you through the treatment. This is someone you can share those HIPAA protected details (unlike social media).
  • Seek education via webinars, online courses, textbooks, journal articles, etc. This is especially important if you see a specific condition, etc. often.

There are some things that I am not competent in treating. Voice is a big one. I have always been uncomfortable with my own voice. My voice class in graduate school was rushed. And I’ve only had a handful of voice patients. Honestly, I am not good at voice therapy.

Thankfully, I’ve got an awesome colleague, who is also a vocalogist, who loves voice. She sings, performs, and has done an impressive amount of continuing education to hone her craft as a singer and therapist. My voice patients go to her, always! They get better treatment from her. She refers to me for my own specialties. She wrote a guest post for us to help us understand vocal changes with aging.

There should not be any shame in not being an expert in all areas of our field or asking for help. As therapists our scopes of practice are diverse. Due to medical advances, our patients are becoming more complex.

How to improve your skill

This month, Gray Matter Therapy will focus blog posts on this very question. We will look at why CEUs are so expensive, recommendations for accruing CEUs as a new clinician (this comes up over and over on forums), assessing education opportunities for usefulness, and more.

In addition, newsletter subscribers will receive a tracking sheet I use to track professional education. It doubles as a record for ASHA and state intervals and an expense report for tax deduction purposes.

American Physical Therapy Association. (No date). Code of Ethics for the Physical Therapist. Available from www.apta.org/policies.
American Occupational Therapy Association. (2010). Occupational Therapy Code of Ethics and Ethics Standards. Available from www.aota.org/About-Occupational-Therapy/Ethics.aspx
American Speech-Language-Hearing Association. (2010r). Code of Ethics[Ethics]. Available from www.asha.org/policy.

Reader Story: “I called the compliance hotline.”

This is a guest post; however, it will not be attributed by name for protection. The writer is a therapist that contacted me several weeks before they called the hotline. We talked through it. They made the call. I’m so proud to share their story. I’ll share your story too.

I am a whistle-blower. Feels odd to say it now that I am past it but just a few weeks ago the idea of being labeled as such was a source of extreme stress!

For months I knew I needed to report my DOR for fraud and unethical behavior, but I was honestly terrified. The DOR was very manipulative and well-liked by staff. I was the new clinician the DOR tried to fire for refusing to pick-up inappropriate patients. I wanted to report the DOR, but I was afraid of retaliation. I was a part of a small therapy team, and I thought the DOR would easily deduce I was the reporter. I also didn’t know what the process behind the compliance hotline looked like, so I kept quiet for months.

Eventually the DOR started to pick on another therapist, who has many years of experience. The DOR would yell at the therapist in front of patients when they said a particular patient wasn’t appropriate for therapy.

The DOR stopped calling our full-time floating therapist in favor of a PRN therapist the DOR knew…and who’s password and user name he had. Documents started getting signed even though none of us had seen the PRN therapist around. As an assistant, the DOR rarely saw patients but continued to bill high minutes. A PRN therapist came in to help with the caseload and patients were confused, because they didn’t know they were receiving therapy!

The DOR required a two week notice for discharges, but would often “lose” or “forget” the notice we gave forcing us to see patients another two weeks.

Early on the DOR tried to convince me to pick-up patients by saying this is all a business. It was stressful to say the least, and there is even more to the story, but it took him yelling at a therapist on our team to make up my mind.

I called the hotline after work one day. The chief compliance officer listened to my concerns and was openly appalled at the DOR’s behavior. The compliance officer assured me they would keep me anonymous by only referring to “the caller” or “the reporter” throughout the investigation. The DOR was suspended, so they could not influence the investigations.

The chief compliance officer did have me send a picture of documents the DOR kept that were against company policy. They also asked me to name specific patients, so they could complete audits of their records. Another officer headed up the investigation for anonymity, so I was interviewed along with my co-workers with same questions and informed that there had been a hotline caller about the DOR.

The DOR resigned a few days into the investigation. While there have been a few whispers among the staff of the SNF of an unnamed “snitch”, all of the therapy staff who worked for the DOR have all noted how relieved we feel and how we don’t dread going to work anymore. Most importantly the patients are finally receiving the therapy they need!

It was a stressful, scary decision, but I would not change my mind for anything. Life is calmer, therapy is better, and I am proud of my company for how they handled my concerns. If you are in a situation similar to mine, please don’t hesitate to call your company’s compliance hotline; my one regret is that I waited too long and endured way more stress than I needed to!

Will unions resolve our concerns?


Bias disclosure: When I started delving into the challenges of healthcare, especially the therapy industry I saw comments from therapists said that we needed a union. My initial reaction was, ‘No, I don’t think unions will solve our problems.’ But then significant time passed and I started to think about unions again, this time wondering if maybe unions would resolve our concerns.

Unions in healthcare

I spent an afternoon at the library browsing through research articles about unions in the healthcare. There aren’t many recent articles. I didn’t review articles that were older than 10 years due to our changing healthcare system.

  • Hospital RN job satisfaction and nurse unions is a 2011 article using survey results from the 2004 and 2008 National Sample Surveys of Registered Nurses to look at the relationship between union representation and job satisfaction. In both 2004 and 2008, union representation had a negative relationship with job satisfaction (though in 2008 results were not statistically significant).
  • The Effect of Registered Nurses’ Unions on Heart-Attack Mortality (full text) is a 2004 article investigating the relationship between union representation and patient outcomes in California. Nurses unions in California with 35% of hospitals having RN unions. This study found that hospitals with nurses represented by unions had a 5.5% lower mortality rate for heart attacks (with control for patient age, gender, and other patient factors). Causation could not be determined.
  • Unions in the healthcare industry (full text) is a 2010 article from a legal perspective. This article provides foundational information to begin to consider unions.

Are unions the solution for therapists?

I reached out to a union organization to find out if unions would solve many of the concerns therapists have. Short answer – probably not.

Here are a few points to consider:

  • In order to form a union, you must have an “appropriate bargaining unit”. This may be your team/facility, region, or company wide. The larger the bargaining unit, the more impact they will have; however, larger bargaining units are much more challenging to organize.
  • PTAs and COTAs cannot join a union with PTs and OTs. American labor law prohibits supervisors from the bargaining unit. Since PTs and OTs have responsibility to direct or assign patient care to assistants, they are supervisors.
  • People employed by the state may not be able to form or join unions. Each state’s laws regarding unions vary.

National Labor Relations Act

One of the enlightening things about the meeting was I learned about the National Labor Relations Act (NLRA). The NLRA was first passed in 1967. In 1974 the NLRA was amended to include nonprofit and for-profit healthcare institutions. The NLRA provided employees with rights including:

  • The right to form or join unions or labor organizations
  • The rights to collective bargaining
  • The right to participated in concerted activity with coworkers for mutual benefit or protection
  • The right to not participate in union activities

The important piece of the NLRA for therapists is the right to participate in concerted activity with coworkers (groups of two or more). This is supposed to protect employees from employer retaliation if they act in groups of two or more to mutual benefit or protection. So if you are planning on acting on October 2nd to stand up for ethical care, don’t do it alone. Find an ally or two. There is power in numbers both in the form of affecting change and invoking protection.

Unions versus associations

One of the things I spoke with the union organizer about was the role of unions versus associations. Unions can speak and collectively bargain for their members; however, associations can advocate for entire groups, even if everyone is not a member. Many of us already belong to professional associations. Yes, I’m looking at AOTA, APTA, and ASHA.

We talked about the option to create a separate association to advocate for these concerns, but it doesn’t make sense to reinvent the wheel if we can get our present associations to continue to advocate (and advocate more strongly) for our concerns. Here are some ways that you can communicate with the associations:

  • Get involved: Join a committee, attend the member meeting at the convention, vote in elections, etc. Find some place where you can dig in and advocate for change within the organization.
  • Speak up: The squeaky wheel gets the grease. Our associations are huge and involved in many projects. If we’re not continually speaking up, other squeaky wheels will get the grease. Write letters in response to articles, blog posts, etc. Respond to the board of director’s activities.
  • Set a trigger: We are all very busy and likely can’t keep track of everything our associations are doing. So set a trigger. When your annual membership fees are due, look to see what your association has been doing. Then write a letter along with your dues that explain what’s good and what needs improvement in how they are addressing issues in elder care. Or maybe your trigger is monthly or quarterly.


Unions may help affect change on the small scale, but I have a large concern with assistants not being able to be apart of the same union. Change would be much more effective on a large scale if assistants were included.

We already have associations, so we should utilize the associations as much as possible. The associations are large already and it would take quite some time to grow a union to be on that scale. Having a larger group will give us more influence, which is important for all of the concerns we eventually want to address. Our associations are already stepping up and advocating against Medicare caps.

Now I know this conclusion may not be in favor for those of you that feel our associations aren’t doing enough or the right things. Don’t give up yet. Our associations are the best resource we have to affecting change from a top-down approach. Speak up and get involved in your association.

And remember, you have the power to speak up in your workplace or leave unethical jobs at anytime. I believe the strongest advocate is the one closest to the source; that’s you.

I want to go to Atlantic City!


This week is National Rehabilitation Awareness Celebration week. For the occasion, I have asked an OT, PT, and SLP to blog about the goal of increasing our patients’ joy rather than just function. I believe this is something that makes our jobs special and something worth celebrating. Please share your story in the comments below to continue the conversation.

Today we hear from Dean Metz, a physical therapist.

The old woman lived 2 flights up in a walk-up apartment building in Harlem. She had arthritic knees and hadn’t left the house in over 6 months. When I asked what she wanted to get out of therapy she replied, “I want to go to Atlantic City!”

The recent retiree met her husband dancing in the chorus of a Broadway Show. For the forty-odd years since they had danced weekly for fun and sometimes for a performance. She now sat dejectedly in own her bed, profoundly debilitated by Guillain-Barre’ which had rendered her paralyzed from the upper chest downward. “I guess dancing at the Waldorf on New Year’s Eve won’t ever happen again,” she said.

The rising force for education of underserved and underprivileged children in the South Bronx sat across from me in his New York apartment. He was giving me a good talking to at our first meeting. He was making it clear that although the fungal meningitis had robbed him of his sight and nearly took his life as well, was not going to stop him from doing anything he wanted to do and I was not to treat him lightly. I said I understood and agreed. With that he excused himself to use the toilet. He stood up on weakened legs and before I could stop or help him, strode his emaciated body into the wall that he could not see. It was then that he cried, not out of pain, although I’m sure it hurt, but fear.

As physical therapists we are often working on function with our older patients. That generally translates into ADLs such as transferring, walking, toileting, bathing and dressing. My OT colleagues get to work more intensely on the iADLs of shopping, cooking, cleaning, the things that we have to accomplish once we are able to perform our ADLs. Sometimes I think we forget about the things that get us out of bed in the first place. The reasons we get dressed each morning and walk out the door. The things we live for, our passions, are the things that often define who we are. Insurance has reduced us to beings that need to be able to rise, dress, wash ourselves and use the toilet alone as needed. If that is all there is to life…well, I guess I can understand why people get depressed and give up.

For a while in my career, I trained new clinicians coming into the company for which I worked. A nurse, whom I respect greatly and with whom I would trust my loved ones, worked alongside me. We disagreed hotly over “the patient stated goal”. I believe that “I want to go to Atlantic City!” is a perfectly reasonable goal which could be broken down to the components needing attention in order to make it happen. For my lady in Harlem it meant getting legs strong enough to negotiate the stairs, endurance to tolerate the trip and the climb back home, managing the pain, an assistive device that would provide the necessary support, instructing family/friends on how to assist as needed. The nurse disagreed stating, “We aren’t providing a bus service to Atlantic City, so we need to make it an achievable goal for us.” She has a point, it’s just one with which I disagree.

I treated that patient in exactly the way I described, always keeping the ultimate goal in mind. She was happy as a clam to once again be pulling the lever on the slots down in Atlantic City!

The dancer slowly regained her strength, but it took months and months. We battled depression every visit, but I also asked to look through her photo albums of shows in which she and her husband had danced nearly every visit as well. Around Easter she was able to transfer from bed to commode independently. Halloween saw her walking with a cane through the neighborhood. You guessed it, she and her husband were able to dance at the Waldorf at New Years. She didn’t have the endurance to go all night, but the point is – she went. I was able to incorporate dance moves (I was a dancer myself 30 years and 50 pounds ago) into her rehab. I would bump into her frequently in the neighborhood, eventually walking without a cane, and she would tell me about the latest dance routines she and her husband were performing.

The younger man was my biggest challenge at that point in my career. I had never worked with someone who was newly blind and learning to negotiate a world of complete darkness, while also bouncing back from being bed ridden for two months. He had no proprioception, no reflexes, and no strength. I listened to him and did not treat him lightly. I pushed hard and he pushed back harder. Working with a trainer from Visions, a service for blind and visually impaired people, we progressed to outdoor gait training. It was a huge benefit to work with other professionals who could fill the gaps in my own knowledge base! Soon he was able to walk his two dogs around the block on his own. That was his goal when I met him. Since then we have stayed in touch. He has wound up teaching me far more than I ever taught him.

He has founded an organization for improving the lives of people with visual impairments, My Blind Spot. His passion was helping those who needed a helping hand and he is doing that once again. In a remarkable side note, when we were practicing his walking outdoors, we passed his car parked on the street. He told me that one-day he would drive again. I said, “OK” and thought little more of it. He proved me wrong. He participated at an event at a racecourse where drivers were blindfolded and paired with sighted navigators and they raced around the track. He was the only one who didn’t need a blindfold. I learned my lesson; never underestimate the abilities of someone who is truly passionate!

When we work with our clients, we must remember that it is not enough to enable them to get out of bed in the morning, but to empower them to have a reason to get up! Tap into someone’s joy, their passion, and the seemingly impossible will be doable.

Guest blogger bio:
Dean Metz has been practicing since 1992, after graduating from SUNY Brooklyn. Most of that time has been with older adults in community care in New York City, Florida, and Northern England. Dean was an instructor with the PTA program of New York University for seven years. He relocated to England for marriage in 2009 and starting working in the National Health Service, giving him a completely new perspective on health care delivery. He earned a Masters in Public Health with the goal of giving rehab a voice in the world of prevention and primary care. Dean’s goal is to move from changing one life at a time to affecting the health of whole populations.

Caregiver training and the gifts of dementia

Heather post

This week is National Rehabilitation Awareness Celebration week. For the occasion, I have asked an OT, PT, and SLP to blog about the goal of increasing our patients’ joy rather than just function. I believe this is something that makes our jobs special and something worth celebrating. Please share your story in the comments below to continue the conversation.

Today we hear from Heather Jeng, a speech-language pathologist.

Speech-language pathologists (SLPs) play a central role in the screening, assessment, diagnosis, and treatment of persons with dementia…Appropriate roles for SLPs include:

  • educating caregivers about possible communication difficulties and providing strategies to facilitate effective communication;
  • developing treatment plans for maintaining cognitive-communication and functional abilities at the highest level throughout the underlying disease course;
  • providing indirect intervention through the individual’s caregivers and environmental modification;
  • providing counseling to persons with dementia and their families regarding communication-related issues and providing information about the nature of dementia and its course;
  • serving as an integral member of an interdisciplinary team working with individuals with dementia and their families/caregivers.

Most common dementia-associated diseases are progressive in nature, and SLPs have an ethical responsibility to provide appropriate services that will benefit the individual and maximize cognitive-communication functioning at all stages of the disease process [emphasis mine].
(excerpted from: ASHA’s Dementia Practice Portal, Roles and Responsibilities)

“Ron” was a retired health care professional diagnosed with Alzheimer’s dementia, exhibiting characteristics of GDS Stage 5, progressing into Stage 6. A friendly gentleman with a smile for everyone, he had been admitted to the skilled nursing facility after an acute illness. The rehab director shared with the team that his family was considering long term care, as caring for him at home had become very demanding. OT, PT, and SLP all received eval/treatment orders for him.

Inspired by laughter

Ron’s wife “Sharon,” arrived at the SNF and greeted me resignedly after I had worked with him the first time. “How did he do for you?” looking like she expected to be told that there was nothing much we could do for him. Her eyes widened as I described the nice conversation Ron and I had had, including him telling me about how much he loved the Porsche he’d once owned, and that his favorite part of being on his college football team was “the cheerleaders…and the beer!” She teared up when I said that we’d enjoyed visiting and laughing. “I can’t remember the last time we laughed together,” she confessed. She shared that she and the rest of the family had “a really hard time” keeping a conversation going with Ron, and the end result was “we just don’t talk to him as much as we used to.” Her fear, she reported, was that the waning interaction was causing his dementia to progress faster.

This conversation was a crucial piece of Ron’s evaluation, allowing the rehab team to link Ron’s bodily functions & structures (what the dementia was doing to his brain) to his activities & participation in everyday life, per the World Health Organization’s International Classification of Functioning, Disability and Health. We continued our conversation into a more formal interview using the ICF checklist to document that Ron’s communicative capabilities were significantly impacted by contextual factors: loving and well-intentioned family caregivers who simply hadn’t been trained in facilitating satisfying conversation with their loved one. As a result, Ron was participating less and less in his family’s social life. Once Sharon realized that best practices for the communication disorders associated with dementia include training family and caregivers, she was excited – and on board.

Sharon participated regularly in Ron’s SLP sessions. At first, she was unsure what to do when her attempts at conversation didn’t elicit a response from Ron. She eagerly watched demonstrations and took home written examples of how to, for example, replace pronouns with people’s names or nouns, and to shorten her sentences, to compensate for Ron’s memory impairments. Soon she was catching herself mid-sentence, and eventually fluidly using these strategies, saying for example, “Katie moved into her dorm last week. Katie’s mom said Katie really likes college so far,” instead of “Katie moved into her dorm last week. Her mom said she really like college so far.” Short-term goals targeted topic maintenance, with Ron increasing the number of meaningful turns he took in conversation, and Sharon directly influencing that by asking questions and making comments that Ron was able to respond to meaningfully.

Family training to recognize ‘gifts’ of dementia

Early sessions focused on introducing and training these types of concrete strategies. As Sharon gained confidence using them, her interactions with Ron opened the door to the “bigger issues” in supporting a spouse through this disease. In My Past is Now My Future: A Practical Guide to Dementia Possible Care©, OTR Lanny Butler, and PT Kari Brizendine, wisely point out that “A ‘gift’ of dementia is the fact that by Stage 5 on the Global Deterioration Scale the individual no longer realizes he/she has memory loss…They no longer worry about their past, nor do they fear the future, they once again LIVE” (42). Sharon reported enjoying longer visits with Ron as she learned to focus on the timeless joys of life with her husband: taking him outside to soak in early fall sun, admiring the view, sharing a home-cooked treat that she’d brought in, and – importantly for another component of treatment – poring over photo albums.

Pam Britton Reese, in her wonderfully practical The Source for Alzheimer’s & Dementia, advises, “…the communication partner needs to realize the joy of reminiscence. Reminiscence (sometimes called recollection or remembrance) is when a person looks back at past events in his life…Persons with AD who can no longer discuss what happened yesterday or an hour ago due to short term memory loss can still take part in a conversation about events that happened long ago” (43). Using Michelle Bourgeois’s Memory Books and Other Graphic Cuing Systems, we collaborated on designing external memory aids specifically for Ron. This included modifying family photo albums that were already put together – labeling names, relationships, places – and creating from scratch a communication memory book for Ron’s frequent family visitors. Over time and with Sharon’s encouragement/insistence, family members elaborated on their visits in Ron’s notebook, providing concrete details (“We brought Danny Boy, the new puppy, to visit. Ron, you LOVED holding him!”) that made Ron smile and comment (“I sure did!”) when staff read the entries to him while helping him to bed.

Celebrating strengths

The staff’s remarks on how much more Ron was talking brings to mind Lanny Butler’s (2005) challenge for us to change our perception of people with dementia:

What we perceive to be true becomes our reality. If we believe that an individual who has dementia is unable to bathe, dress, feed, and toilet themselves, that will become your loved one’s reality, only because you have made it so for them. Often, we unknowingly take away these abilities, out of love, but also out of ignorance of what can be done. By doing for them, we have taken away their ability to participate in life and have taken away much joy we could have shared together (p. 1).

In Ron’s last session, Sharon echoed Mr. Butler’s sentiments when she concluded, “We didn’t know what to do. We just thought he couldn’t talk with us like he used to. But he could still! We just had to change what we were doing.”


  • Bourgeois, M. (2007). Memory Books and Other Graphic Cuing Systems: Practical Communication and Memory Aids for Adults with Dementia (1 edition.). Baltimore: Health Professions Pr.
  • Butler, L. & Brizendine, K. (2005). My Past Is Now My Future (1ST edition.). Lynchburg, Va.: Warwick House Publishing.
  • Dementia: Roles and Responsibilities. (n.d.). Retrieved September 13, 2014, from http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935289&section=Roles_and_Responsibilities
    Reese, P. B. (2000). The Source for Alzheimer’s & Dementia. East Moline, IL: LinguiSystems.
  • Reisberg, B., Ferris, S. H., de Leon, M. J., & Crook, T. (1982). The Global Deterioration Scale for assessment of primary degenerative dementia. The American Journal of Psychiatry, 139(9), 1136–1139.
  • WHO | International Classification of Functioning, Disability and Health (ICF). (n.d.). Retrieved September 10, 2014, from http://www.who.int/classifications/icf/en/

Guest blogger bio:
Heather Jeng, M.A., CCC-SLP has worked primarily in skilled nursing/long-term care facilities. She graduated from Case Western Reserve University. She is currently pursuing a doctoral degree in Speech & Hearing Sciences at the University of Washington in Seattle, working in the Motor Speech & Cognition lab. Her main interests are Parkinson’s, TBI, dementia, and translational speech-language pathology/Practice-Based Evidence. She serves on ASHA SIG 15′s Continuing Education committee. She and her husband have two cats, though sometimes they wonder if the cats have them.

Inactivity in SNFs: How We Are In an Optimal Position to Elicit Change


This week is National Rehabilitation Awareness Celebration week. For the occasion, I have asked an OT, PT, and SLP to blog about the goal of increasing our patients’ joy rather than just function. I believe this is something that makes our jobs special and something worth celebrating. Please share your story in the comments below to continue the conversation.

Today we hear from Christine Ebrahim, an occuputional therapist student.

During my first encounter interning in a SNF, “Charles”, a long-term resident of the facility, would wheel himself into the therapy room to chat with me. In our brief but sweet encounters, he would share poetry he had written throughout his lifetime, emphasizing that nothing made him happier than to share his words with someone who appreciated them. He memorized the days I would be there and greeted me with a warm smile and a copy of a different piece he’d written.

The staff was not comfortable with Charles being in the gym since he was no longer receiving therapy, and wouldn’t be unless he experienced a decline in function. This was an understandable concern, as the small gym in the facility could barely accommodate those that needed care as it was. As Americans are living longer than ever and life expectancy is increasing every year, this has resulted into an overcrowding of SNFs – a phenomenon many of us are unfortunately all too familiar with (“Life expectancy”, 2014).

But Charles didn’t care about this. He was looking for an opportunity to meaningfully socialize during the long hours of the day. And for this reason, he told me, “I wish I was still in therapy.”

As therapists in a SNF, we generally work with individuals who are brought to us from local hospitals. It is absolutely important for us to provide the best quality of care for those on our caseloads.

But what about those not under our care anymore? What about the large quantity of residents who permanently reside within the facility, and are not given enough of a chance to express themselves, engage in personally-chosen or meaningful activity, or derive a sense of purpose through interaction or hobbies? What about those who are simply incapable or unwilling to be involved in the activity room? What can we—already busy enough as it is—do to help?

Meaningful Occupations

Occupational therapists have been trained to consider “meaningful occupations”, or activities, in every step of the therapeutic process. Researchers Christiansen, Backman, Little, and Nguyen (1999) confirmed the belief that people derive satisfaction from successfully accomplishing activities they find personally meaningful in their lives.

A well-known intervention study, the Well Elderly Treatment Program, found that the inclusion of a self-directed occupational therapy program aimed at maintaining and reintegrating older adults into their activities of interest had powerful and lasting therapeutic effects that radiated to numerous dimensions of their well-being (Jackson, Carlson, Mandel, Zemke, & Clark, 1998).

This focus on meaning is integral to the care of clients—regardless of our individual disciplines. I propose that we, as therapists, make it a primary aim to ensure that a client has the opportunity for these “meaningful occupations” well after discharge. This is so important, especially in a SNF where the chance for meaningful activity may be interrupted.

How to Plan for Meaningful Occupations

First, it’s important to establish a genuine relationship with a client, where we gather a sense of who they are and what matters to them. This relationship not only enhances the therapeutic process, but it builds an understanding about what will help them to thrive. If we are aware of what motivates them, we are much more likely to establish ways for them to use their time meaningfully—even well after discharge. This is especially important for clients, who will be living at the facility long term.

If we know what makes someone feel accomplished, purposeful, or provide a sense of being productive, we can make recommendations to them, their family members, or caregivers that can be implemented throughout their stay. In the case that a client does not have anyone, it is up to us – trained professionals – to ensure that this person will not be discharged to sit or lie in his or her rooms. This is where our knowledge of what the client enjoys comes handy.

Simple Solutions Facilitate Activity

A personalized calendar that is posted in a client’s room in a great way to ensure that activities they’ve chosen to participate in is visually reinforced. This can be supplemented with an agenda, photos of themselves completing the activities, a family member or caregiver who encourages activity participation, and other methods of motivation.

Those with little mobility, low cognitive function, or no verbal ability can engage in all sorts of activities that might be meaningful to them, as well. In fact, activities for people with dementia may be more important to their psychological well being than the physical and social environment they are in (Marshall & Hutchinson, 2001).

Charles loves writing poetry. Although he has difficulty writing nowadays, the activity can be adapted for him by consulting with a regularly-visiting family member and finding out whether this person would be willing to transcribe his words for him. Perhaps a schedule can be set to motivate Charles to produce work as regularly as he sees fit. From there, since Charles loves sharing his poetry, he can have copies made to disperse within the facility or mailed to those who would appreciate his work. This does not take a lot to effort to coordinate and provides him the opportunity to remain active in an area that reaffirms his purpose.

As we begin to think about the longevity of our clients’ care in therapy, we can become far more skilled in ensuring that they are taken care of well after they are discharged. Other caregivers need to be involved in the maintenance of meaningful occupation plans, but we are in an optimal position to get the ball rolling for our client to remain active, providing them meaning and purpose while residing in a SNF – long after we stop seeing them.


  • Christiansen, C.H., Backman, C., Little, B.R., Nguyen, J. (1999). Occupations and well-Being: A study of personal projects. American Journal of Occupational Therapy, 53(1):91-100. doi: 10.5014/ajot.53.1.91.
  • Jackson, J., Carlson, M., Mandel, D., Zemke, R., & Clark, F. (1998). Occupation in lifestyle redesign: The well elderly study occupational therapy program. American Journal of Occupational Therapy, 52(5), 326-336.
  • Life expectancy. (2014, July 14). Retrieved August 26, 2014, from http://www.cdc.gov/nchs/fastats/life-expectancy.htm
  • Marshall, M., & Hutchinson, S. (2001). A critique of research on the use of activities with persons with Alzheimer’s disease: A systematic literature review. Journal of Advanced Nursing, 35(4), 488-496.

Guest Blogger Bio
Christine Ebrahim is into her second year of completing her M.S. in Occupational Therapy at California State University, Dominguez Hills. She holds a special interest in the ethical treatment of clients, the application of the outdoors/nature into therapy, and neurorehab. Find her on Facebook or LinkedIn.