For the love of Speech, Language, Voice, Swallowing, & Cognition; oh, and helping.

I help people; it’s what I was born to do.  When I’m at a party, I help serve drinks, pass out food, set up, tear down, and/or clean up.  I can’t help myself.  When I hear a friend has a problem, I’m compelled to solve it.  It takes more effort to NOT help than it does for me to help.  I can’t even say it’s an obsession; it’s just me.  That’s the driving factor into my chosen profession of speech language pathology.

When I graduated with my master of science degree I couldn’t wait to get out in the world so that I could help people; older people specifically.  The picture I had in my mind was me, visiting residents in skilled nursing facilities, and doing everything I had just learned how to do to help them.  Then, my employers and patients would be ever so thankful for the difference I had made, and I would feel wonderful about life & my chosen career path.  I didn’t expect a ticker-tape parade or anything, just smiling happy people who would say, “thank you for doing a good job.”

I had a very rude awakening when I started working full time.  I quickly learned that when corporate involved in healthcare, it became less about helping and more about money.  Honestly, excuse the cussing; it PISSED ME OFF.

I was allowed a few months to get used to working and translating the skills I had learned at school, and then I was expected to meet certain requirements.  Those requirements lessened my ability to do the excellent helpful therapy I wanted to do, so that I could make non-therapeutic, but necessary, tasks “billable,” meaning the corporation could make money from it. 

I began getting written-up because I refused to use my face-to-face therapy time for calling their family in front of them, or typing notes on the computer while I tried to guide them through a therapeutic activity–

BY THE WAY, have you ever tried to conduct swallowing trials with a demented patient while writing a note that justifies their service to Medicare????

Imagine this:  Patient Bob (PB) has mid stage dementia; he likes to “fiddle” with items in front of him.  I’m supposed to be working on his swallowing.  I’m sitting with him at lunch (because it’s the most functional time to work on swallowing) and I have 30 minutes with him.  He has a progress note due today, so I need to take my computer to the dining room and type his note while we work on swallowing.  PB likes to put large bites in his mouth, he doesn’t chew his food, he doesn’t clear his mouth before he puts more in, so I am working on changing that pattern.  With PB, I need to cue him (verbal instruction) to take less on his spoon, and then watch him to make sure he chews, swallows, and takes a drink before he puts more food in his mouth.  For each bite.  In a dining room, where he (and I) is distracted.  But, when I try to feed him in his room, he won’t eat; he needs the visual cues of his peers eating to cue him that it’s time.  And he likes to fiddle, right?  So that means when I look away, he is grabbing food off of someone else’s tray, or he’s pouring his drink onto his food (or in his neighbor’s food) or he is trying to drink his milk using his spoon as a straw or trying to use his straw as a spoon.

Now, this isn’t PB’s fault is it?  No!  That’s why I’m doing therapy!  But, I’m sure you can tell, PB is a hands-on type person.  He is not the kind of person I can just stop watching and type a progress note! 

I need to provide cues with my speech, my touch, my facial expressions AND analyze his behavior and figure out how I can use my fancy-schmancy master’s of science in speech language pathology degree to help him be able to eat, maintain his nutrition, without choking or aspirating. 


But that’s what is expected.  I could have anywhere from 9-15 people to see during my day; all of them would require a daily note, which should take about 5 minutes to type, depending on the day, half of them could require a progress note (those are due 1x every 2 weeks).

So let’s do math.  I’ve got 10 people on my schedule to be seen for 50 minutes a piece.  that’s 500 minutes of my work day, which works out to 8.3 hours.  That’s no time to use the bathroom, no 15 min break, no time to walk in the hallway between patients without going into over time.  PLUS I have to write notes.  So, I can’t see everyone for 50 minutes; let say I see them for 30 minutes; that’s 5 hours.

If I actually do speech therapy without typing, I have 50 minutes of daily notes to do, and then half of patients have progress notes, so that’s 5 notes at 15 minutes a piece.  That’s 75 minutes worth of progress note writing.  That’s a 425 minute work day, roughly 7 hours. 

NO bathroom breaks, no time to talk to the nurses about a new resident who may or may not need therapy, no breaks, no time to call the hospital SLP with questions regarding the swallow study or mental status during their acute care stay, no time to even say, “how are you doing” to my co-workers.

Let’s say I was at work for 425 minutes, 300 of them were in front of a patient, actually working on therapy, or what’s called “billable time.”  That means I was 70% productive, meaning I spent 70% of my day in front of my patients, which the company can now charge the health insurance company for. 

Well, my readers, that’s not good enough for corporate.  When I started they wanted 85%.

Corporate now wants SLP’s to be 90-100% productive.  Ideally, in a perfect world, that feels like it should be doable.  But the problem is:  it doesn’t lend to great therapy.

Subpar therapy means Pt’s stay in facility longer, because they can’t meet their therapy goals.  Which means more money for them & the Medicare system to pay (** us working folks pay for Medicare, remember).  It also means slower bed turn-around for the facilities, which decreases their profit.  They get more from the people within their first 90 days of Medicare Part A.

But honestly, I don’t care about the money– I LIKE TO HELP PEOPLE.  And the corporate rules + bureaucracy doesn’t allow me to do that to the very best of my abilities.  It makes me type when I should be giving cues or instructions.  It makes me focus on getting in and getting out, rather than what type of approach I will use.  It makes me make poor decisions about who to group, so I can at least have time to pee without getting in trouble. It makes me unable to establish a positive relationship with the nurses, kitchen staff, housekeeping staff, and the MD because I’m so concerned about numbers.  It makes me want to to be dishonest about how long I actually spent with the patient, just to get my boss of my back for not being good enough for the company.  

And now, the payment model has changed. (I’m so thankful I left that setting when I did.)  Now some companies are requiring SLP’s to see patients FOR NO MORE THAN 15 minutes. 

Let’s say my friend PB comes back from the hospital after having a CVA, and he has a new diagnosis of dysphagia, plus aphasia, in addition to his underlying dementia.  That means, as his SLP, I need to address 3 issues within the therapy setting: swallowing, language, and attention/memory.  Except, I only have 15 minutes to work on it and then I have to leave his room and move to my next patient.

Oh, and the productivity expectation went up, too.  Now I have to be 100%.   

Excellent therapy?  Nope!

Is that the kind of therapy you want to be doing?  How about paying for?  How about receiving?  How about your family member receiving?

Not this speech language pathologist! 

Michelle in full PPE

I write all of this to educate you.  This is what happens when a larger corporation gets involved in health care.  It is wrong on so many levels… but the level I care about MOST, is helping my patients.

I opened Resurgence Neuro Rehab so that I could provide the quality of speech, language, voice, swallowing, or cognitive evaluations and therapy I know I’m capable of providing.

I opened Resurgence Neuro Rehab so I can provide a holistic, integrative, patient-specific approach to therapy in order to promote overall health and well being for the individual.  

I opened Resurgence Neuro Rehab so I can take the time to investigate and address the underlying issues resulting in the communication or swallowing problem, not just treat the symptoms.  

I opened Resurgence Neuro Rehab so that I can provide education to families about diseases, conditions, resources, and other services that may help improve quality of life and life satisfaction.

I opened Resurgence Neuro Rehab so that I can influence change in the current health care system and make it more about actual healthcare and not as much about making money.

I opened Resurgence Neuro Rehab so that I provide extraordinary speech language therapy services to adults in & around Cabarrus county, on my own terms; using the equipment and approaches that have been proven by research to work.

 I want to help people.  I want to help people swallow better, speak better, understand better, think clearer… so that they can live out the rest of their lives, doing what they love to do, and be happy doing it.

Life is too short to do and be anything but that!


Michelle Hill MS CCC-SLP is a speech language pathologist and Owner/Founder/CEO of Resurgence Neuro Rehab.