Key to Reimbursement
Both short- and long-term goals may be scrutinized in order to determine whether skilled speech therapy services are medically necessary in the SNF setting, as well as in other settings involving adult and geriatric patients, such as Home Health Care (HHC) and Assistive Living Facilities (ALF). It is the responsibility of the SLP to clearly define reasonable goals using professional skills. This is where documentation programs and "drop down" menus or goal banks can lead us astray. Every goal must be personalized to address each patient individually.
Most SLPs I know focus on helping the patient first, as we should. We cannot help patients, however, if our services are not justified by our goals and weekly notes. The weekly progress note must assess each goal and demonstrate progress. But, wait; what if a patient did not make progress in a certain goal? At this point, we may have to:
- Document whether the patient needs more or less cueing. Is the type and amount of cueing appropriate?
- Adjust the targeted accuracy and/or change the amount or type of cues.
- Determine whether the goal is appropriate.
- Document why progress has not been made. Did the patient decline due to a new onset of an illness? Was there a family or personal situation that interfered? Have medications been adjusted?
- Adjust the date that we expect the short-term goal to be met.
There are times when we observe the very subtle, almost immeasurable improvements our patients achieve. We know our services are helping that patient to communicate, swallow and participate in their daily routine. But, if from week to week, we can only document consistently a patient is 80-90 percent intelligible or able to use a chin tuck on 80 percent of swallows with mod cues, we are not showing progress but maintenance. Maintenance is not a skilled service, so either the patient is ready for discharge, having reached his or her highest functional potential for that goal, or the accuracy, frequency, or cueing hierarchy must be adjusted.
Likewise, target dates for short-term goals must be adjusted as the patient progresses. Target dates for achieving short-term goals are developed when the patient is evaluated, but weekly progress notes provide us with the ability to upgrade the expected date short-term goal might be achieved based on progress, which allows us to facilitate maximum functional potential in use of targeted skills.