How do you assess and treat dysphagia in the home?

As a Home Health SLP, I am often asked the same questions.  How exactly do you do dysphagia assessment and treatment in the home?  So many other therapists want to see what I do differently than in any other setting.

The truth is,  I don’t change a thing!  

Being in the home opens up a world of opportunity though that you often don’t get in a more sterilized environment.  Now, don’t get me wrong.  Every setting has ups and downs.  

Gathering pertinent information

When I go to evaluate a patient that has recently returned home, the great thing is that they have often already had a Videofluoroscopic Swallow Study (VFSS) or a Flexible Endoscopic Evaluation of Swallowing (FEES).  Now, getting the report can often be the difficult part, however I have found that the doctor’s office can be a great source to share the report as they often have a copy.

The evaluation on my part is no different however than in any other setting.  If I have the VFSS or FEES report available, I will  review the report and any notes from nursing prior to my evaluation.  It’s also always nice to have a family member present if available.   They will often tell you what the patient does not.  

I interview the patient and family member (when available).  I want to know what happened prior to the hospitalization. Was there actually difficulty with swallowing prior to hospitalization.  I want to know what they were working on in the hospital/rehab and what they are doing now.  What is the recommended diet and are they following it.  I don’t ask about following a diet to scold them.  If they haven’t been following the diet and have no compromise from that, I like to know that.  It gives me a good idea of possibility of diet upgrade.  

Assessment protocol

I still do an oral mech exam, I do a cranial nerve exam.  I may use the MASA if I need a standardized score to report.  I also use the Functional Oral Intake Score (FOIS) to measure outcome by diet level.  

Not sure about the cranial nerve exam?  Do you assess symmetry and movement of the lips, the pucker, smile, taste?  You just assessed Cranial Nerve VII the facial nerve.  Do you assess for pocketing, mastication, jaw movement?  You just assessed Cranial Nerve V, the Trigeminal Nerve.  Do you assess movement and symmetry of the tongue?  That’s right!  Cranial Nerve XII, the Hypoglossal Nerve.  Now nerves IX and X are difficult to assess without instrumentation as those nerves are largely responsible for pharyngeal function.   

I may even have the patient eat something for me.  The best part of home health is that most patients have food.  If not, I do keep some non-perishable items in my car that can be used in a pinch.  

Implementing treatment and “home practice”

In the home setting, I use a tablet to document and my company uses PointClick Care for documentation.  This allows me to fill in fields and to also free-hand my findings.  I also have to free-hand my goals, which I like because I am definitely not a fan of pre-fabricated goals!

I like my dysphagia goals to be functional for the patient.  The goal may be to swallow X consistency using such and such compensatory strategies.  The goal may be without strategies.  It really depends on the patient and their wants and needs.

My evaluation and treatment always begins with a good lecture on oral care.  I explain how aspiration pneumonia can occur.  When bacteria in the oral cavity is aspirated with a liquid or food and travels to the lungs without being cleared.  I explain to the patient how important oral care is when swallowing and often ask that they complete oral care prior to eating rather than after.   Since most patients are fairly stable after returning home, I often initiate the free water protocol with them after education on oral care.  Most are grateful to be able to have regular water when other liquids have to be thickened.  

Every single patient receives a Home Exercise Program.  Now, exercises are dependent on the patient and their physiological deficit.  I don’t give a standard set of exercises and most times I give 1, maybe 2 exercises to complete.  I find that we can actually target more using this approach and that the patient tends to be more compliant.

Compliance

Speaking of compliance…… I always, always, always educate on each exercise I have the patient complete and tell them why they are doing each exercise.  It helps the patient to become motivated if they know why they are doing what they do.  I often find that I also have a lot of education on thickening liquids, if they require thickened liquids.  Many times though, in the home, patients do not thicken their liquids.  They may say they do.  I can check the canister of thickener and see that they either haven’t opened it or that they have opened it and the amount hasn’t changed.  This is also good for me to know because it gives me an idea of how they are handling the liquids without the thickener.

I often use a very food-based approach with patients.  If the patient is NPO, we may start with ice chips or a very small amount of water after good oral care.  Often, if I tell the patient in advance what we are going to work on and what I’d like to work with, they will have the food/liquid/ice in advance.  

The exercises are very much dependent on the patient as I said.  If I have a patient doing a Chin Tuck Against Resistance (CTAR) I often have them do it against their fist, a rolled towel or will buy them a small ball at the dollar store.  I write out each exercise for the patient to complete outside of ST sessions and I work with them on swallowing food/liquids.  

Benefit of home environment

The great part of being in a person’s home is the intimate setting.  You definitely can build a great relationship with your patient and their family in a setting where the patient is relaxed and comfortable!

Links of Interest

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Tiffani Wallace, MA CCC-SLP, BCS-S
Tiffani Wallace is a Speech Language Pathologist with 17 years of experience. Tiffani is a Board Certified Specialist in Swallowing and Swallowing Disorders (BCS-S). She works full time in home health, is the owner and author of the blog Dysphagia Ramblings and the owner and endoscopist at Hoosier Mobile Dysphagia Solutions offering mobile FEES for NorthCentral Indiana. Tiffani is the co-author of the apps Dyspahgia2Go and Dysphagia Therapy and the author of the app iScreen Aphasia. Tiffani travels around the country speaking on the topic of dysphagia and has created several Webinars for SpeechPathology.com and Norther Speech Services. Tiffani was also on the podcast Swallow Your Pride on episodes 2 and 50. Tiffani is the creator and administrator of multiple Facebook groups focused on dysphagia including Dysphagia Therapy Group Professional Edition. Tiffani is also the co-author of the upcoming book The Adult Dysphagia Pocket Guide Neuroanatomy to Clinical Practice from Plural Publishing.

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