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So this woman (or man) walks in to your office…

If your staff has been nagging you about bringing a mobile fiberoptic endoscopic evaluation of swallowing (FEES) service provider in for a meeting, then this is the place for you! We know you think that Speech Pathologists have been specifically trained to make diet modifications, trial compensatory strategies, and teach evidence-based treatments to their patients, and we absolutely have! But, we do not have x-ray vision. Simply put, we can not see what we can not see. Research has shown a 70% error rate in bedside swallowing exams where recommendations were either too restrictive, leading to dehydration/malnutrition, or silent aspiration leading to pneumonia was missed.

You would never want a physical therapist to tell your grandmother who has a suspected broken hip to get out of that bed and walk without an X-ray, in the same way that Speech Pathologists can not make appropriate recommendations without imaging. We need to see the anatomical and pathophysiological deficits in order to make the appropriate recommendations. Some exercises and strategies such as thickened liquids have been shown to actually cause harm to a patient and potentially a subsequent re-hospitalization, if they are indicated for an unnecessary reason. Once we have obtained baseline imaging, then we can use our clinical judgement to form a treatment plan.

There are 3 scenarios when a SNF will want to refer a patient for a mobile FEES:

1 A long term resident suddenly is having difficulty at meals. The Speech Pathologist will evaluate them and make recommendations. The appropriate next step is to schedule a mobile FEES. We are able to determine if there has been a major change in swallowing pathophysiology due to an underlying medical condition, or it may be excess secretions due to seasonal allergies causing a dysphagia, or even a reflux medication is no longer working and the patient is aspirating their own back flow. There is a plethora of conditions that we are unable to treat without knowing the underlying cause.
2 If time allows, a patient with a suspected oropharyngeal dysphagia will have an MBSS prior to leaving the hospital. However, due to staffing issues, or weekend discharges, or the radiologist flat out denying anymore MBSSs for the week (or month, yes this really happens), the SNF is now responsible for obtaining the imaging. Instead of calling the hospital and waiting 3-4 weeks to send them back for an MBSS and risking aspiration pneumonia and a potential re-hospitalization in the meantime, call us, we’ll be there in 1-2 days.
3 MBSSs are done in the hospital when the patient is acutely ill. The recommendations are made to discharge the patient out as quick as possible. After spending a few weeks and regaining strength, a patient may be ready for an upgraded diet. Speech Pathologists will trial several consistencies and strategies at the bedside to assess for compliance and tolerance, but we do not want to write the order to the doctor recommending the diet upgrade across all meals without imaging. Silent aspiration is often missed at the bedside, and we aren’t certain if the strategies we are recommending are helping or hurting the patient. The mobile FEES procedure is done right at the bedside, utilizing your facility’s meals and thickened liquids to maintain consistency with our recommendations. We speak with the SLP, nurses, and family to ensure that the recommended strategies and diet consistencies are realistic.

Have confidence in your staff…

There has been an increasing presence of questioning regarding instrumental swallowing assessments from Medicare, the Court systems, and the Department of Health. It is the responsibility of all staff, nurses, and Speech Pathologists to ensure that the patients are compliant with the recommended diet and compensatory strategies. On the flipside, there is also a new wave of patient’s rights advocates to ensure that the patient is satisfied with their stay at the SNF and ultimately their current diet. Oftentimes, we find a struggle between what the SLPs observe at the bedside, nurses trying to carry out the guesstimated compensatory strategies, all while the patient is dissatisfied and refusing the recommended diet.

A FEES can give a real time objective image of the swallow so that the appropriate recommendations for diet and compensatory strategies can be made. The SLP now has an objective measure to educate the nurses, and can discuss with patient and family as to the reasoning behind the recommendations. All is well that ends well.

We don’t want to be locked in to a contract…

A mobile FEES procedure provides objective, measurable data to prove medical necessity of speech therapy services and document progress, or lack thereof, and to justify accurate calculation of RUG levels. How many times have you doubted yourself as a clinician, wasn’t quite sure how to document the suspected problem, or just unsure which exercises to do? With a mobile FEES done in the patient’s natural environment, you are now able to confidently take the documented impairments and look up the most research based treatments for this underlying pathophysiology. No more arbitrary lingual exercises for everyone, real EVIDENCE-BASED patient-specific treatments. Having a mobile FEES done at the bedside allows for the flexibility of time. There are no radiation restrictions or barium limits that have to be followed. If you are suspecting fatigue with a patient, the study can be performed for the entire meal. Have you ever recommended a diet only to have the CNAs tell you that after 15 minutes he’s too tired to stay upright in his ‘perfect eating positioning’ and is coughing and choking on everything? The MBSS is great at giving us an objective snapshot of the swallow, but is not ideal for a patient that fatigues easily. A mobile FEES procedure provides a realistic assessment, and captures the “true picture” of what is happening at meals by the patient self feeding in his/her natural eating position over time.

What’s it going to cost me?

We understand the importance of keeping costs down and not ordering tests for unnecessary reasons. We charge 1 all-inclusive rate that is well below the national average. We do not charge mileage unlike other companies, regardless of the distance traveled to you. Our price is approximately 1/3 of the cost of sending a patient to the hospital for an MBSS. When the MBSS is done in the hospital, there are charges for speech therapy, radiology, barium, and transportation. Most times, the radiology costs are billed in one lump sum from the hospital to the SNF annually. Most facilities do not realize the MBSS makes up a large portion of that bill, We’re sure you have an awesome CFO and he will be able to look that up.

We also do not bill you if the patient does not participate, although we do have 99.997% success rate with passing the scope (yes that is an actual figure, and no we did not bill the facility for that .001%). There is nothing worse than spending money on transportation and sending a CNA with a patient to the hospital for an MBSS all to find out that he did not want to play nice when he got there. Not only have you wasted money on the ambulance and CNA, he has now missed all of his therapy for the day, missing OT/PT/ST minutes, and subsequently disrupting RUG levels.

We come to you and the Speech Pathologist is able to bill for their treatment minutes while assisting with the mobile FEES procedure. No disruptions in productivity, even if our patient decides he does not want to participate. We have had several patients with dementia or generalized anxiety where they agreed to participate and once it came time for the test, they had a change of heart. No harm, no foul, no invoice, no missed minutes. We rescheduled with the family or a CNA they felt comfortable with, and we were able to obtain the necessary imaging that was drastically different to what was observed at the bedside.

Reduce Re-hospitalizations and other cost savings:

The following five conditions – congestive heart failure (CHF), upper respiratory infections (URI), urinary tract infections (UTI), sepsis, and electrolyte imbalance -all account for 78% of all 30-day SNF re-hospitalizations, and have all been deemed as potentially avoidable. CHF can be reduced by adherence to any fluid or dietary restrictions. URIs may be reduced by following appropriate positioning of residents with swallowing problems to avoid aspiration that could lead to pneumonia. UTIs, sepsis, and electrolyte imbalance can all result from dehydration or poor nutrition, which may be prevented with careful monitoring of patient fluid and nutrient intake. All of these have been found to be preventable with a mobile FEES procedure. As explained above, nothing good happens when the patient does not agree with or is not capable of following the recommended diet or compensatory strategies.

As discussed above, often patients comes from the hospital on a modified diet and/or thickened liquids and as their overall condition approves, a diet upgrade is often necessary, but the diet upgrade doesn’t always occur. Some patients can live at a SNF for several months, and even years before a family member stirs the pot to see if they may be appropriate for an upgrade. The cost of keeping 1 patient, just 1 out of 100s of residents in your facility on thickened liquids for 1 year costs approximately $7,000 in annual operating costs. Just think of how many residents may be living at your facility that have been on thickened liquids for an extended period of time! Also keep in mind, that overall physical condition has no correlation in requiring thickened liquids. The oldest, weakest, and frailest of them all have been known to live out their years happily drinking thin liquids.

So to help you recap: You can spend upwards of $1600 to send your patient to a hospital for an MBSS that can not visualize some of the conditions that are prevalent in the geriatric population, then spend upwards of $35,000+++ for a re-hospitalization, then when they come back from the hospital on thickened liquids, you can tack on $7,000 that year to cover the cost… Or you can spend a couple hundred bucks to have a mobile FEES done at the facility.

A recent study found that SNFs that have access to mobile FEES show a significant increase in instrumental assessments, and subsequently a significant reduction in pneumonia rates in that  same group. I’m sure you would love to throw those bragging rights around along with you new found cost savings!

Provide your patient with an evidence-based, cost effective, live video,
that is a GOLD STANDARD in swallowing diagnostics.


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