MANAGEMENT OF MEDICALLY COMPLEX PATIENTS IN LONGTERM CARE

1
MANAGEMENT OF MEDICALLY COMPLEX PATIENTS IN
LONG-TERM CARE
Susan Almon-Matangos, Regional Clinical Director
Laura Maxwell, District Manager
Jodi Czernejewski, Regional Clinical Director
Bill Goulding, National Director of Outcomes and
Reimbursement
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Program Goals

• Identify and describe specific medically complex
  disease processes.
  
• Perform effective assessments
• Utilize a variety of therapeutic strategies
• Develop effective treatment plans/goals
• Document medically complex conditions
• Analyze outcomes data for medically complex
  patients with speech/language/swallowing deficits
  treated by Aegis Therapies

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Medically Complex Definition

• A medically complex patient has co-morbidity of
  several medical conditions often with a
  cardiopulmonary overlay that significantly
  compromises ability to function.

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What constitutes a medically complex patient?

• Nursing skilled
• Presence of exacerbation and remission
• Special challenges including
• Low tolerance
• Refusals
• Low motivation
• Little observable progress in function

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Functional Problems of the Medically Complex

• Increased anxiety during activities
• Decline in ADLs
• Not participating in ADLs
• Refusal to participate in therapy or activities
• Low endurance
• Orthostatic hypotension
• Decreased speech production

• Shortness of breath
• Decreased participation
• Decreased intake
• Increase in edema in extremities
• Decrease in cognitive status
• Confusion during or after an activity
• Decreased tolerance to pain

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Restore, Compensate, Adapt

• RESTORE
• Increased respiratory support
• Increased coordination of swallow/respiration
• Effective use of relaxation if struggle is
  affecting function
  
• Compensate
• Training for patient in thinning secretions
• Swallow techniques
• Voice amplification devices
• Adapt
• Diet modification
• Skilled training for staff in cueing needs and
  importance of monitoring
  

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MEDICALLY COMPLEX CONDITIONS

• Respiratory
• Cardiovascular
• Metabolic
• Infection/Other

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RESPIRATORY

• Pneumonia
• COPD
• Emphysema
• Chronic Bronchitis
• Asthma
• Restrictive Lung Diseases
• Atelactasis

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PNEUMONIA

• Definition-acute infection of the lung tissue
  that commonly impairs gas exchange with viral,
  bacterial, fungal, aspiration etiology (most
  common cause is aspiration)

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CHRONIC OBSTRUCTIVE PULMONARY DISEASE

• Definition Chronic airway obstruction
  resulting from emphysema, chronic bronchitis,
  asthma, or any combination of these diseases
  caused by smoking, recurrent, or chronic
  respiratory infections, air pollution, and/or
  allergies.

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EMPHYSEMA

• Definition abnormal, irreversible
  enlargement of air spaces distal to terminal
  bronchioles due to destruction of alveolar walls,
  resulting in decreased elastic, recoil properties
  of lungs caused by smoking, deficiency of
  alpha-antitrypsin.

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CHRONIC BRONCHITIS

• Definition excessive mucous production with
  productive cough for at least 3 months a year for
  2 consecutive years caused by smoking,
  respiratory infection.

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ASTHMA

• Definition A reversible obstructive lung
  disorder, characterized by increased
  responsiveness of the airways often of allergic
  origin.

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ATELECTASIS

• Definition A collapsed or partially collapsed
  condition of a lung or portion of a lung, most
  commonly caused by mucus plugs occurring in those
  with COPD, bronchiectasis, cystic fibrosis, and
  those who smoke heavily or suffer from prolonged
  immobility. Occlusion may also occur from
  foreign bodies, pulmonary edema, external
  compression (tumor, pneumothorax), and
  inflammatory lung disease.

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RESPIRATORY TREATMENT CONSIDERATIONS

• Ventilatory strategies
• Breathing strategies
• Energy conservation
• Relaxation
• Positioning
• Controlled breathing
• Controlled huffing and coughs at low volumes for
  COPD
  
• Adequate hydration (12-15 glasses per day)
• CO2 retention versus O2 saturation for COPD
• O2 saturation versus CO2 retention for pneumonia
• Coordination of speaking/breathing
• Clearance/thinning of secretions/airway
  clearance
  
• Incentive spirometry for inhalation problems
• Trigger avoidance for asthma

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CARDIOVASCULAR

• Congestive Heart Failure
• Hypertension

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CONGESTIVE HEART FAILURE

• Definition A decrease in the myocardial
  contractile state such that cardiac output is
  inadequate for the bodys needs caused by
  ventricular failure, CAD, myocarditis,
  cardiomyopathy, infiltrative disease, valvular
  heart disease.

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HYPERTENSION

• Definition intermittent or sustained elevation
  in diastolic or systolic blood pressure caused by
  heredity, race, stress, obesity, high intake of
  saturated fats or sodium, use of tobacco,
  sedentary life style, and aging

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TREATMENT CONSIDERATIONSCONGESTIVE HEART FAILURE

• Prolonged bed rest
• Proper positioning for eating/speaking
• Analyzing physical response to speaking or eating
  by monitoring blood pressure, pulse, edema
  
• Coordinate breathing with activities
• Deep breathing and coughing
• Anti-embolism stocking to prevent venostasis and
  thrombo-embolus formation
  
• Range of motion exercises to increase/maintain
  strength/coordination with close monitoring of
  vital signs

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METABOLIC

• Renal Failure
• Diabetes

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RENAL FAILURE

• Definition failure of kidneys to remove waste
  products and water from blood stream caused by
  chronic glomerular disease, infections (such as
  TB), congenital anomalies, vascular diseases
  (such as HTN), endocrine diseases (such as
  diabetes), obstructive processes (such as
  calculi), collagen diseases (such as lupus),
  nephrotic agents.

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TREATMENT CONSIDERATIONSRENAL FAILURE

• Fluid restrictions
• Oral hygiene
• Nutritionsmall portions of high calorie food
• Deep breathing and coughing to prevent pulmonary
  congestion

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DIABETES MELLITUS

• Definition disturbance in carbohydrate,
  protein, and fat metabolism resulting in absolute
  or relative insulin deficiency or resistance
  
• Causes
• Type 1 often thin, prone to ketoacidosis,
  usually early onset
  
• Type 2 family history, race (Black/Latino/Native
  American), HTN, obesity, sedentary life style,
  and aging.

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INFECTION / OTHER

• Sepsis
• Orthostatic hypotension

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SEPSIS

• Definition fever, chills, and other reactions
  of the body to bacteria or their toxins in the
  bloodstream caused by transplantation of bacteria
  to a person who already has weakened condition,
  often due to surgery, IV therapy, and catheters.
  Often occurs in individuals hospitalized for
  primary infection of the genitourinary, biliary,
  GI, or gynecologic tract.

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Screening for Medically Complex Patients

• Medicare A patients not on therapy.
• Patients observed in dining room to have issues
  with exertional tolerance during mealtime.
  
• Medication changes.
• Residents not improving with nursing
  intervention.
  
• Condition reports of falls, weight loss, or
  wounds.
  
• Caregiver reports of patients who are not
  participating or exhibiting shortness of breath.

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AGE-RELATED CHANGES

• VITAL SIGNS FOR THE OLD-OLD PERSON COMPARED WITH
  A YOUNGER ADULT

Vital sign Adult 18 85 over
Temperature (F) 98.6 degrees 95-97 degrees
Pulse Rate 70 (male) 70-75 (may be
(BPM) 75 (female) lower at rest)
Respiration 15 - 20 20 - 22 (more (breathes
/min) shallow) Blood Pressure 120/80 140
/90 (mm Hg)
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SLP Treatment Guidelines

• Physiologic body responses to speaking and
  eating
  
• Respiratory sufficiency during speech
• Cognitive assessment and training
• Oral motor skills
• Overall communication status
• Need for voice prosthesis or adaptive equipment
• Dysphagia and feeding
• Monitor and educate re side effects of meds
• Psychosocial skills

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ASSESSMENT

• Medical History
• Diagnosis, family, and conditions
• Medications, current lab tests and X-ray
• Nutritional status
• Patient Interview
• Current function/symptoms
• Therapy history/treatment goals
• Observation
• General appearance
• State of consciousness/orientation
• Posture
• Reading paragraph

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UNDERLYING CAUSES OF FUNCTIONAL DEFICTS FOR
MEDICALLY COMPLEX PATIENTS

• Respiration
• Rapid/inefficient
• Decreased chest expansion
• Decreased diaphragm movement
• Kyphosis
• Light headedness/dizziness
• Fatigue

• Other medical or medication effects
• Cough ablilty
• Sputum
• Edema
• Appetite depression
• Emotional problems
• Cardiac problems
• Anxiety and tenseness

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PHYSICAL ASSESSMENT

• General Appearance
• State of consciousness/orientation
• Breathing patterns
• dyspnea
• nasal flaring with inspiration (severe
  respiratory distress)
  
• use of accessory muscles (increased work of
  breathing)
  
• Ability to complete full sentences
• Skin coloring
• Clubbing of fingers (chronic cardiopulmonary
  disease)
  
• Bilateral pedal edema (chronic right heart
  failure or renal failure)
  
• Distention of neck veins (elevated central venous
  pressure)
  
• Breathing should be determined w/patient at rest,
  when hes unaware his breaths are being counted.
  
• Breathing pattern Include ratio of times for
  inspiration and exhalation (normal 12 or 13
  with pause after exhalation) symmetry and
  synchrony of chest and abdominal movement in
  supine abnormal breathing patterns.

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PHYSICAL ASSESSMENT (Continued)

• General Appearance
• Posture
• Use of upper extremities to stabilize thorax.
• Resting position such as forward leaning in
  sitting or relaxed standing against a wall to
  decrease the work of breathing
  
• Presence of deformities indicating
  musculoskeletal adaptations to chronic disease
  
• Kyphosis barrel chest
• Pectus excavatum - funnel chest
• Pectus carinatum - pigeon chest

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PHYSICAL ASSESSMENT (Continued)

• Kyphosis barrel chest
• Pectus excavatum - funnel chest
• Pectus carinatum - pigeon chest

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SLP Guide to Lab Work
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TAKING A PULSE

• Wash hands
• Explain procedure
• Clean equipment
• Locate site
• Warm stethoscope
• Listen/count for 15 seconds
• Record results
• Note steady increase/decrease, increase with
  activity, full or bounding (forceful), thready
  (weak), length of time after stopping activity to
  return to normal.

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TAKING BLOOD PRESSURE

• Wash hands
• Explain procedure
• Clean equipment
• Place cuff one inch from brachial artery
• Feel radial pulse as you inflate cuff
• Place stethoscope over brachial artery
• Deflate cuff slowly
• First sound from artery is systolic
• Final sound is diastolic
• Record results

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AUSCULTATION OF BREATH SOUNDS

• Observe chest movement
• Explain procedure
• Clean/prepare equipment
• Auscultate breath sounds beginning at anterior
  thorax, moving L-R, R-L, assessing one full
  breath at each point
  
• Auscultate anterior/posterior/lateral thorax
• Classify breath sounds by location, intensity,
  pitch, and duration during inspiratory and
  expiratory phases.

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PULSE OXIMETRY

• Wash hands
• Explain procedure
• Clean/prepare equipment
• Place sensor on patients finger
• Wait for stable reading
• Record oximetry and pulse results
• Special considerations
• Affected by light/motion
• Fingernail polish must be removed

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INCENTIVE SPIROMETRY

• Wash hands
• Explain procedure
• Clean/prepare equipment
• Auscultate lungs for baseline comparison
• Insert mouthpiece
• Exhale normally, Inhale slowly/deeply
• Rest/cough
• Repeat 5-10 X
• Compare auscultation
• Wash and store spirometer

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Dyspnea Scales

• Visual Analog Scale
• Rancho Los Amigos Dyspnea Scale
• Perceived Dyspnea Scale (Modified Borg Scale)

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Visual Analog Scale

• How much shortness of breath are you having right
  now Please indicate by marking the heights on
  the column. If you are not experiencing any
  shortness of breath at present, circle the mark
  at the bottom of the column.
• Shortness of breath as
  bad
  
• as can be imagined.

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Rancho Los Amigos Dyspnea Scale

• 0 Dyspnea the patient is unaware of the need to
  breathe
  
• 1 Dyspnea the patient has slight awareness of
  the need to breathe the subject can hold a
  conversation
  
• without difficulty.
• 2 Dyspnea the patient is definitely aware of
  the need to breathe rate and depth of
  breathing increases and accessory muscles
  begin to function, the patient breathes in
  mid-sentence or shortens sentences in order
  to breathe.
• 3 Dyspnea breathing is rapid and deep
  accessory muscles are prominently
  functioning conversation is short and
  choppy, and the patient must breathe after
  three or four words.
• 4 Dyspnea conversation at this point is
  difficult to elicit from the patient
  one-word answers or the inability to speak is
  common the patient may nod to indicate yes
  or no.

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Perceived Exertion

• For the person who has compromised
  cardio-respiratory function, even the simplest
  activity such as eating can be perceived as
  taxing
• BORG SCALE RPE-RATE OF PERCEIVED EXERTION
• 0 NO WORK
• 0-5 VERY LIGHT
• 1
• 2 LIGHT
• 3
• 4 FAIRLY LIGHT
• 5
• 6 FAIRLY HARD
• 7
• 8 HARD
• 9
• 10 VERY HARD

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Ventilatory Response Index (VRI)

• Procedure The patient is asked to breathe
  normally. Following a normal inhalation, the
  patient counts aloud to 15 over a 7.5 to 8-second
  period, taking additional breaths as necessary.
  A may be used to indicate a hurried count.
• Level Definition
• Level 0 Able to count aloud to 15 in 8 seconds
  without taking a breath.
  
• Level 1 Must take 1 breath in 8 seconds in order
  to complete counting aloud to 15.
  
• Level 2 Must take 2 breaths in 8 seconds in
  order to complete counting aloud to 15.
  
• Level 3 Must take 3 breaths in 8 seconds in
  order to complete counting aloud to 15.
  
• Level 4 Must take more than 3 breaths in order
  to complete counting aloud to 15.
  
• From Cardiopulmonary Physical Therapy, 1999, by
  the Cardiopulmonary Physical//therapy Section of
  the American Physical Therapy Association.

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Edema

• Edema
• Note periorbital edema
• Mild-to-severe or pitting edema may be observed
  primarily in the ankles or sacrum.

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Skin Turgor

• Skin Turgor
• Purpose To evaluate hydration.

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Cough Ability and Sputum

• Cough Ability Describe as strong, moderate,
  weak, or unable
  
• Sputum Characteristics
• Mucoid
• Purulent
• Fetid
• Bloody

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Assessment

• Respiratory function
• Cardiovascular function
• Endurance
• Poly-pharmacy
• Functional activity assessment.

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TREATMENT GOALS

• Improved ability to perform ADLs
• Decreased symptoms
• Increased endurance and strength
• Improved quality of life
• Decreased negative consequences of deconditioning
  
  
• Decreased risk for concomitant pathologies
• Return to pre-admission living site

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Recommended Interventions with Medically Complex
Patients

• Assessing the reason for refusals.
• Treat during normal daily routine to conserve
  energy.
  
• Involve patient in goal setting.
• Improve endurance.
• Assess polypharmacy.
• Prioritize therapy conditions and needs.
• Emphasize compensate/adapt.
• Revise goals frequently.
• Use treatment gym when not busy.
• Treat in room.
• Keep therapy sessions short.
• Treat BID or split.
• Check activity levels before mealtime if intake
  is a problem.
  

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Sample Short-term Goals

• Respiration
• Patient will increase respiratory support for
  speaking/eating as demonstrated by sustained
  phonation of 12-15 sec.
  
• Patient will increase respiratory support for
  speaking/eating as demonstrated by incentive
  spirometry reading of 1200cc/sec.
  
• Patient will increase breath support for
  eating/speaking and decrease aspiration risk by
  maintaining O2 sats at 97-100.
  
• Patient will increase respiratory function for
  speaking/eating as demonstrated by decrease on
  visual analog scale from ___ to ___.
  
• Skin turgor
• Patient will decrease dehydration as demonstrated
  by increase in skin turgor from poor to good.
  
• Perceived exertion
• Patient will increase endurance for
  eating/speaking as demonstrated by decrease in
  Borg Scale from 6/10 to 2/10.

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Sample Short-term Goals

• Perceived exertion
• Patient will demonstrate increased activity
  tolerance as demonstrated by the ability to
  engage in a 5 minute conversation with Borg PRE
  score of
• Patient will demonstrate increased activity
  tolerance as demonstrated by the ability to
  engage in conversation with family with a Borg
  PRE score of
• Patient will demonstrate increased activity
  tolerance as demonstrated by ability to self-feed
  50 of meal with Borg PRE scale of
  sats 90.
• Oxygen saturation levels
• Patient will demonstrate increased activity
  tolerance as demonstrated by ability to sing a
  hymn at church service with O2 sats 90, and
  increase in HR of

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Physiological Monitoring

• Heart Rate and Rhythm (normal 60-100 bpm)
• Oral Temperature
• Blood Pressure Normal blood pressure is 120/80,
  for the elderly 140/90.
  

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Physiological Monitoring

• Heart rate and rhythm (normal 60-100 bpm)
• Sample STG- To increase oral intake from 25 to
  75, patient will maintain HR at 70-75BPM before
  and after eating.
  
• Blood pressure (normal blood pressure is 120/80,
  for the elderly 140/90)
  
• Patient will maintain BP at 140/90 or less
• after engaging in telephone conversation with
  daughter for 5 minutes.
  

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DIAPHRAGMATIC BREATHING

• INDICATIONS COPD, post-operative, dyspnea,
  diaphragmatic weakness
  
• PROCEDURE
• Position/demonstrate
• Physical pressure to abdomen
• Instruct patient to breathe in, push abdomen out,
  as SLP counts to 3, hold breath for count of 3,
  exhale for count to 3 and extend to 6.
  Exhalation should be twice as long and
  inhalation.
• Breathe in through nose, out through pursed lips
• Have the patient inhale and exhale while
  producing a voiceless fricative, beginning with
  h and progressing to s, th, f, and sh.
  
• Increase volume, going from soft to loud, then
  decrease the volume. Start with s and then move
  to more difficult phonemes.
  
• Ask client to exhale while counting in one
  breath, with slow voice and decreased volume,
  counting 1-2-3 and increasing to 10.
  
• Practice in various positions (sitting, standing)
  and activities 3-4 X daily
  
• Document improvement in perceived exertion,
  dyspnea, ability to complete ADLs

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Head and Neck Resistance Exercises

• Purpose
• To increase pharyngeal/laryngeal function
• To improve posture
• Position
• Exercises

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PURSED-LIP BREATHING

• INDICATIONS dyspnea
• PROCEDURE
• Position/demonstrate
• Physical pressure to abdomen
• Instruct patient to breathe in to count of 2
• Breathe in through nose, out through pursed lips
• Exhale to count of 4.
• Practice in various activities 3-4 X daily
• Document improvement in perceived exertion,
  dyspnea, ability to complete ADLs
  

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INCENTIVE SPIROMETRY

• Place patient in semi-Fowlers position
• Have patient take 4 relaxed breaths.
• Exhale into spirometer on 4th breath.
• Slowly inhale , monitoring the rise of the
  indicator ball.
  
• Maintain full inspiration as long as possible
• Remove mouthpiece and passively exhale.
• Repeat 10 X, several sets daily.
• Document increase in maximal inspiration.

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COUGHING

• Preferred position is sitting up straight,
  leaning forward slightly.
  
• Have patient take slow, deep breath.
• Have patient cough 2-3 times during exhalation,
  using abdominal muscles.
  
• Increase lung volume by 3-5 inspirations without
  expiration.

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MANUAL COUGH

• Position may be supine, sitting, or standing.
• Place hand in CPR position 2 inches below
  xiphoid.
  
• Have patient breathe in.
• Patient exhales and attempts to cough while
  therapist pushes up and in.
  
• Patient can be taught to perform manual cough on
  self.

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ENERGY CONSERVATION

• Guidelines Is the activity necessary? If so, is
  it necessary for the patient to perform it, or
  can it be delegated to another?
  
• Perform the activity in an energy efficient
  manner
  
• Pace the performance of activities

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Work Simplification

• Plan ahead.
• Plan all the steps involved.
• Analyze the sequence of events.
• Choose the work place based on convenience to
  needed supplies or equipment and ease of use.
  
• Determine the best time of day to perform the
  activity.
  
• Organize the activity.
• Gather all supplies/equipment necessary for the
  activity prior to beginning.
  
• Store items where they are most frequently used
  (duplicate if necessary).
  
• Use the best equipment for the activity.
• Use an assembly line approach to performing the
  activity.
  
• Have the necessary equipment/supplies within
  comfortable reach, but not in the way.

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Oxygen Therapy Policy and Procedure

• Points
• Equipment
• Nasal cannula
• Facial mask
• Oxygen administration

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Oxygen therapy policy and procedure

• Points
• Smoking is prohibited while oxygen is in use.
• Monitor oxygen flow rate and concentration as
  ordered by the physician.
  
• Use a mask if flow-rate to be delivered is over 6
  liters.
  
• For flow-rates of 4 liters per minute or less
  with nasal cannula, humidification is optional
  and should only be used if clinically required or
  ordered by physician.
• The physicians order must specify oxygen flow
  rate and method of administration.
  
• Equipment
• Source of oxygen - pressurized oxygen cylinder on
  stand (E tank or H tank), oxygen concentrator, or
  liquefied oxygen, with tags for full, empty, or
  in use. Rip off tag to correct level when
  returning to storage.
• Oxygen in uses / No smoking signs.
• Oxygen flow meter and gauges.
• Adapter as appropriate.
• Humidifier bottle, either pre-filled/sealed or
  reusable/disposable with distilled water supply
  (pre-filled preferred).
  

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Documentation

• 700
• 701
• Weekly progress notes
• Functional maintenance plan tips

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Documentation
NO JOB IS FINISHED UNTIL THE PAPERWORK IS DONE!
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Documentation

• 700
• Onset date within 90 days.
• Prior history should paint a picture of the
  patients history and current status.
  
• Diagnosis - Primary diagnosis is determined by
  Physician. Use only approved ICD-9 Codes for the
  facility or intermediary. Treatment diagnosis.
  
• Reason for referral should contain the
  circumstances and impairments that led to therapy
  referral. This statement establishes medical
  necessity by stating what might happen if patient
  does not receive therapy, and emphasizing safety
  risks and possible further declines.
• Current level of function should be documented in
  percentage of trial and indicate the cueing
  levels when appropriate. Formal tests should be
  used as appropriate. For medically complex,
  assessment data should include measurements of
  the patients physiological response to the
  activity, such as oxygen saturation levels,
  pulse, respiration or perceived exertion.
• Discharge plan contains expected living
  arrangement and level of assistance.
  
• Short-term goals should include each deficit
  noted in the assessment or state reason for
  deferral. Short-term goals should be limited to
  the amount of progress that can be achieved by
  the end of the certification period.
• Long-term goal should be the functional
  objective(s) expected at the time of discharge.
  It should be measurable, functional, and
  sustainable.

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Documentation

• 701
• Justify the need for continued skilled care.
  Functional level refers to the progress attained
  with your treatment during the month. Progress
  needs to be documented in measurable terms. Any
  functional changes, medical problems, change in
  frequency of treatment, addition of new
  modalities, adaptive equipment provided, etc.
  Needs to be included. Documenting in a positive
  manner will justify continuation of services.
• Weekly progress notes
• Weekly notes should be no more than 7 days apart.
  Compare current week to past week. Keep short
  term goals in order and continue reporting on
  them until they are met or discontinued. If
  underlying deficits are used as short term goals,
  be sure to tie them back to function in the
  analysis portion of the note. Analysis should
  talk about how progress on the treatment
  objectives moved the patient closer toward
  achieving the functional goals. Skilled service
  should be explained and documented.

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Documentation

• Functional Maintenance Plan Tips
• FMP should clearly state what the CNA/RNA should
  look for. Examples SOB, color, coughing.
  
• Note need for cueing/pacing in performing
  functional tasks.
  
• Note need to coordinate with nursing for
  breathing therapy and meds.
  
• Note need to coordinate restorative activities
  into daily routine, such as dressing or eating
  and not having extra time/sessions for activities
  due to poor endurance.
• Educate staff about disease process and expected
  behavior patterns. Examples Martha will want a
  fan in her room at all times. She will not take
  a shower after 5 other people have been in there
  due to steam buildup. She will have anxiety
  attacks.

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SLP Outcomes Overview with Medically Complex
72
SLP Outcomes Overview with Medically Complex

• Initial disability 1.41
• Discharge function 2.19
• Gain 0.60
• Length of stay 24.3 days
• Discharge to the community 35.58

73
SLP Outcomes Overview with Debility

• Initial disability 1.39
• Discharge function 2.15
• Gain 0.78
• Length of stay 25.5 days
• Discharge to the community 29.59

74
SLP Outcomes Overview with Medically Complex

• Initial disability 1.41
• Discharge function 2.19
• Gain 0.60
• Length of stay 24.3 days
• Discharge to the community 35.58

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SLP Outcomes Overview with Debility

• Initial disability 1.39
• Discharge function 2.15
• Gain 0.78
• Length of stay 25.5 days
• Discharge to the community 29.59

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SLP Outcomes Overview with Circulatory Disorders

• Initial disability 1.49
• Discharge function 2.25
• Gain 0.77
• Length of stay 23.4 days
• Discharge to the community 41.68

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SLP Outcomes Overview with Respiratory Disorders

• Initial disability 1.39
• Discharge function 2.18
• Gain 0.79
• Length of stay 24.1 days
• Discharge to the community 32.76

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SLP Outcomes Overview with Infectious and
Parasitic Disorders

• Initial disability 1.39
• Discharge function 2.17
• Gain 0.78
• Length of stay 24.2 days
• Discharge to the community 38.27

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SLP Initial Disability with Medically Complex
80
SLP Discharge Function with Medically Complex
81
SLP Gain with Medically Complex
82
SLP Length of Stay with Medically Complex (Days)
83
SLP Percent Discharge to Community with Medically
Complex
84
SLP Gains in Speech Production
85
SLP Gains in Voice
86
SLP Gains in Swallowing
87
Amount of GainSLP Outcomes with Medically Complex
88
SLP Length of Stay with Medically Complex
89
SLP Discharge to Community with Medically Complex
90
QUESTIONS?