After reading Rebecca’s post about how using ASHA’s Evidence Maps can save us time, I wondered how much time it would actually take to use ASHA’s Evidence Maps to find something useful for my patients.
Outline:
- Why I haven’t been using ASHA’s Evidence Maps regularly.
- The challenge I took.
- 1. Bulbar onset ALS.
- 2. Aneurysm with rupture during surgery.
- 3. Multiple strokes with attention as main problem.
- 4. Cerebral palsy with new AAC device.
- 5. Right MCA stroke with word finding deficit.
- Why using ASHA’s Evidence Maps is worth it.
- Take the 5 minute challenge.
- Related Eat, Speak, & Think posts.
Why I haven’t been using ASHA’s Evidence Maps regularly
When I started home health around five years ago, I was suddenly working with people who had a much wider set of problems than I was used to seeing. I researched practically every patient I worked with, and I was also doing a ton of continuing education courses.
This took hours of time outside of work. ASHA started producing their Evidence Maps in 2010, but they weren’t on my radar. Rebecca’s premise that using the Maps would save time would definitely have been true for me at that time.
Now, after more than 10 years as a speech-language pathologist, I don’t often research specific patients. For most of my patients, I feel comfortable that I know what to do. I already work long hours. So the question for me is, would starting to use the maps regularly be a burden? Or would taking the time be a real benefit to my practice?
The challenge I took
I thought it would be interesting to search the Evidence Maps on behalf of my current patients to see if I found new treatment ideas.
Here is what I learned after searching on behalf of five patients currently on my caseload.
1. Bulbar-onset ALS
The first patient I ran through the Evidence Maps was an elderly gentleman newly diagnosed with bulbar-onset ALS. So new that I was the first speech-language pathologist that he was talking to.
I have a lot of experience working with people who have ALS (for instance, see this guide), so I wasn’t expecting to find anything useful.
I learned I was wrong in less than five minutes.
Assess ability to use email and social media
I’ve always been hesitant about embracing electronic forms of communication, likely stemming from the fact that I finished graduate school in 2008 when not as many people were using email and social media. I had gotten the idea that we were supposed to treat face-to-face and telephone communication and that insurance wouldn’t pay for intervention involving email and social media.
Of course, many of my patients now use email and social media as a routine communication method. I’ve directly treated the use of email but never social media (not beyond showing someone how to access it on an eye-gaze communication device).
So I was relieved to see in black and white that assessing and treating the use of email and social media as communication methods is recommended.
Reminder to assess rate of speech
I do assess the rate of speech when a person presents with a noticeably slower rate. But I don’t always assess rate of speech as a baseline measure when rate of speech appears normal.
Of course, in a degenerative disease it’s an important measure because it provides objective data regarding progression. In this case, I simply forgot. So seeing this recommendation served as a reminder to me.
A new assessment tool
The ASHA Maps pointed me to the Short Form Health Survey (SF-36), which is freely available. Patients can complete this quality of life questionnaire online (and print it) or you can save it as a PDF.
Reminder to talk about EMST
Here’s another example of something I know, but forgot to bring up in the initial session. Admittedly, the initial session was packed with information for my patient and his family, since I was the first SLP they talked to about the new diagnosis of ALS. But I don’t know if I would have remembered to bring it up as an option during a later session.
Mild-to-moderate expiratory muscle strength training (EMST) and lingual resistance training are options for patients with ALS. I always clear this with the doctor before starting exercise with someone who has a degenerative disease. I’ve never had a neurologist say “no”, but I don’t want to take the chance.
2. Aneurysm with rupture during surgery
I picked up a new patient with short-term memory complaints following the surgical removal of an aneurysm which bled during surgery. I didn’t find an evidence map, but a quick search on ASHA’s website turned up a guideline that supported assessing cognitive-communication skills.
As a clinician who was going to assess her cognitive-communication skills anyway, this didn’t add anything.
However, I followed the link to the American Heart Association’s guidelines for aneurysmal subarchnoid hemorrhage which I skimmed to gain a sense of what this was and how it was treated. It didn’t change anything I did with my patient (and I’m not even 100% that this is my patient’s diagnosis), but it was interesting to see just how serious this condition is and how it’s medically treated.
3. Multiple strokes with attention as main problem
Another patient I’m working with has had multiple strokes which has affected cognitive-communication skills with deficits in attention, memory, reasoning and problem solving, and executive function skills. Language skills are intact.
There are 115 articles for stroke in ASHA’s Evidence Maps.
I refined it by selecting “treatment’, “cognitive/linguistic”, and “attention” which dropped it to a much more manageable five articles. I chose to focus on attention as this deficit is affecting my patient in many ways.
Computer training for attention and working memory
The Evidence-based review of stroke rehabilitation: 17th edition has a lot of information. What I found most relevant was that “an intensive, computerized training program may result in improvements in both working memory and attention.” My patient uses an iPad, so we’ll use that for some therapy exercises.
Attention Process Training
There’s evidence to support Attention Process Training (APT), but it’s quite expensive. What I learned was, sadly, there’s a treatment with some evidence that’s currently out of my reach.
Stroke Rehabilitation Clinician’s Handbook
And following a link to the Heart & Stroke Foundation Canadian Partnership for Stroke Recovery led to the 39-page Stroke Rehabilitation Clinician’s Handbook (2016). This is a great resource ,which I suggest you check out. For this patient I was especially interested in Section 5: Cognitive Rehabilitation.
Specific recommendations for attention therapy
Section 5 of the Clinician’s Handbook is 39 pages long. “Cognitive Rehabilitation for Attention, Memory, Executive Function” starts on page 13.
Based on what I read, these are the key take-aways for my patient:
- Use non-speeded tasks.
- Choose complex tasks involving selective or divided attention.
- Don’t rely solely on apps; include training for actual tasks my patient wants to improve.
4. Cerebral palsy with new AAC device
I’m picking up a new patient who has cerebral palsy with a recent decline in speech and a new AAC device. My patient hasn’t been trained to use the device.
Searching ASHA’s Evidence Maps for cerebral palsy and narrowing by “adult” and “treatment” led to two articles. One’s on swallowing, which is not relevant to my patient. The other is “The Morphology and Syntax of Individuals Who Use AAC“, which is relevant.
It conveniently lists the interventions to improve use of AAC: “models, contingent queries, recast expansion, forced choice alternative questions, and correction of incorrect form and explanations of grammatical rules.” (Click on “Cerebral Palsy” under Conclusions From This Systematic Review).
5. Right MCA stroke with word-finding deficit
The last patient I’ll share had a right middle cerebral artery stroke with the sole complaint of a mild word-finding deficit.
In the time it took me to generate orders in my EMR, I was able to search the Evidence Maps and see that my plan to use Semantic Feature Analysis (SFA) was appropriate.
I selected the Stroke Evidence Map and refined by “treatment” and then “word-finding treatments” (last option under Speech and Language Treatments). This resulted in four articles, and I was quickly able to see that SFA was the best option for my patient.
So, in under five minutes and while I was waiting for my computer to process each step for generating orders, I was able to see that I’m probably not missing a good treatment avenue for my patient.
Why using ASHA’s Evidence Maps is worth it
It’s fast
I spent around five minutes on each of these patients, except for #3 when I found the Clinician Handbook and started reading.
We can improve our care on a patient-by-patient basis
Our field is advancing every day, and we all know it’s not possible to keep up on everything.
Just as we wouldn’t want a cancer doctor treating us with 10-year-old techniques that “get results”, we shouldn’t persist in using “tried-and-true” techniques if there are newer methods with more evidence.
Using the Maps can expose us to new assessment and treatment methods and resources.
It reminds us of things we already knew
I pointed out a couple times above that searching the Evidence Maps reminded me of things I already knew to do but had forgotten.
We can confirm that our care plan is appropriate
Searching the Evidence Maps allowed me to confirm that my treatment plans included appropriate evidence-based interventions.
It supports better outcomes, which payors expect
I imagine that we all see our patients getting better, to some extent, as a result of our therapy. If they didn’t, we probably wouldn’t last long in our positions.
But the questions are how much recovery do our patients see and how long does it take?
I think that’s at the heart of the reimbursement changes with PDPM and PDGM. CMS wants to pay for the most effective and efficient therapy.
Using the Evidence Maps will help us to choose interventions that have been shown to make a difference and deliver them effectively.
Take the 5 minute challenge
If you’re not already using ASHA’s Evidence Maps, take five minutes and search on behalf of one of your patients. You may be pleasantly surprised to find something useful!
Related Eat, Speak, & Think posts
- How ASHA’s Evidence Maps save you time.
- 5 ways I improved work-life balance as a home health SLP.
- 7 tips to benefit your home health patients and minimize your workload.
Featured image by Honey Yanibel Minaya Cruz on Unsplash.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
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