Co-Author: Stephanie Watts, PhD, CCC-SLP

In this article, we journey through the idea of, and potential for, a multidisciplinary swallowing clinic (MSC) in your practice. We (1) explore the concept of MSC in reference to model types, (2) interview experts, (3) hear patient experiences, and (4) outline a pathway to success. Given the inherent complexity of dysphagia, every SLP has experienced the need for multidisciplinary care. You may have encountered one of the following patient scenarios:

A. The patient with previous head and neck cancer who is status post-surgical intervention and chemoradiation. There is pharyngeal phase dysfunction that is amenable to rehabilitation. However, there is a focal cervical esophageal narrowing just below the cricopharyngeus (CP) which is partially obstructive to bolus flow.

In scenario A, you acknowledge that this structural barrier must be addressed prior to intensive swallowing rehabilitation. You recommend an ENT or GI consultation to facilitate dilation, typically done during an esophagogastroduodenoscopy (EGD).

B. The patient with scleroderma has normal mechanics of the oropharynx, but formal screening of esophageal clearance reveals significant retention and backflow of the bolus to the CP, meeting failed criteria for both anatomic abnormality and dysmotility.

In scenario B, you recommend a GI consultation to further investigate the suspected structural and physiologic impairment causing incomplete esophageal clearance. This would include EGD and esophageal manometry (EM). 

C. The patient with acute onset dysphonia and dysphagia for three weeks. Oropharyngeal mechanics are adequate with exception of laryngovestibular closure resulting in routine trace aspiration with thin liquids. Only one vocal fold is moving during voicing tasks in A-P view under fluoroscopy.

In scenario C, you are concerned for a unilateral TVF immobility and recommend an ENT consultation for thorough laryngeal evaluation. You start intervention, but you hope that the patient will undergo injection laryngoplasty.

D. The patient with gastroesophageal reflux disease (GERD) is found to have significant cricopharyngeal muscle dysfunction (CPMD) that is partially obstructive to bolus flow. Formal esophageal screening is unremarkable.

In scenario D, you realize that the CPMD is a physiologic barrier that needs further work-up to identify the cause. Since CP intervention should await the completion of comprehensive reflux testing, both ENT and GI should be consulted. pH-metry can be completed by Bravo capsule placement under EGD or using a transnasal catheter. Findings will guide intervention. 

E. The patient with a history of skull base tumor resection resulting in extensive and profound pharyngeal and esophageal dysfunction due to unilateral CN X involvement. The patient has been feeding tube dependent and NPO for four months. 

In scenario E, you want to begin swallow rehabilitation, but realize that the patient would significantly benefit from a prosthetic or pharyngoplasty to address the VPI, laryngoplasty for the paralyzed VF, and thorough assessment of dysmotility (EM) and lower esophageal sphincter (LES) dysfunction (EGD with Endo Flip) before any CP intervention. You recommend an ENT, GI, and prosthodontic consultation to facilitate all the above. 

MULTIDISCIPLINARY MODEL TYPES 

The practice patterns of an SLP are integrated with consideration of the following models (Starmer et al., 2020):

Wheel and Spoke Care Model 

This is a traditional outpatient care model. Imagine each of the patients in the above scenarios presents to the physician (Primary Care Physician (PCP)) and reports “swallowing difficulty”. The physician has the option to consult SLP, ENT, or GI. If the patient presents with other concerning symptomatology, the patient may be sent to other specialists such as Neurology, Rheumatology, and Pulmonology. 

Pros

  • The patient has seen a physician who manages medical conditions and medications. 
  • The patient will, at one point, see the referred specialist, have the swallowing complaint evaluated with some sort of testing (EGD, HRM, barium esophagram and/or VFSS) and return to see the PCP to review and coordinate care based on results of the consultations.

Cons

  • The patient may wait a considerable amount of time to be evaluated by the specialist.
  • Often only a segment of the swallowing continuum is evaluated; therefore, recommended interventions are limited to that context.
  • The specialists are often not communicating with each other, and the PCP is left to juggle and analyze the pieces of the swallowing puzzle as consultation results/recommendations are completed.

Multidisciplinary Review Care Model

This care model is like a head and neck tumor board. A patient’s case is brought to the board by at least one specialist attending the meeting, and findings of the assessment are presented to other specialists. 

Pros

  • Multiple specialists can weigh-in on additional assessment and intervention. 
  • Team input and discussion helps to specify next steps in the evaluation and/or management of the patient, which can reduce some patient burden (time and energy).

Cons

  • The patient will still need to complete further work-up with other specialists.
  • The plan of care may change based on findings of that specified work-up (patients are often re-presented throughout the process of comprehensive work-up until completion).

Integrated Multidisciplinary Care Model

The ENT, GI, and SLP are together in one room with the patient for comprehensive evaluation and collaboration on the care plan.

Pros

  • The patient undergoes fluoroscopic and endoscopic evaluations by the specialists in one day, so multiple components of their swallowing continuum / aerodigestive tract are considered.
  • The specialists review the results of the evaluations together and with the patient so that they are on the same page about structure and function as well as safety and efficiency.
  • The specialists and the patient collaborate on the best plan moving forward in further working up or managing the patient’s swallowing complaints.
  • The patient generally feels more comfortable with the plan because it was devised and supported by the expert group in consideration of the patient’s goals.
  • If further work-up is needed, the patient will leave the clinic with an established plan of care including appointments. Further discussion can take place at the monthly multidisciplinary review board.

Cons

  • The team may experience barriers from administration in terms of clinical practice space and workflow.

INTERVIEW WITH EXPERTS

Mayo Clinic Arizona has held both integrated MSC and review board meetings for over a year. The genesis for this clinic was initiated by SLP, Jessica Gregor, then brought to fruition through the support of ENT and GI. The essential partnership with these disciplines is the driving force behind improved patient outcomes. We asked about the physician perspective on the MSC.

Dr. David Lott is a laryngologist and chair of the Otolaryngology department at Mayo Clinic Arizona.

“Before this clinic, I felt handcuffed on what I could do for our patients. My knowledge base was confined to a singular ENT view of swallowing. This clinic is the pinnacle of patient-focused care. It allows for interpretation of patients’ symptoms from different viewpoints and a multi-expert discussion of the treatment plan including patient input. Being able to work with Jessica and Allon has helped round out my view of swallowing and have a better understanding of pathologic processes and other treatment options.”

Dr. Allon Kahn is a gastroenterologist specialized in esophageal diseases at Mayo Clinic Arizona. 

“Looking back, I had a narrowed view of swallowing solely from an esophageal pathology standpoint. Often the patient was referred out, and I didn’t like that feeling. When Jessica pitched this idea, I was intrigued by the opportunity to collaborate in providing the full spectrum of dysphagia care to patients. Participating in the clinic has completely transformed my understanding of swallowing dysfunction and has changed my own practice when seeing patients alone. I simply didn’t know the things I didn’t know about the other specialities!”

PATIENT EXPERIENCES

Patient perspective is powerful. Below are direct quotes from patients who have benefitted from an integrated care model:

“I haven’t had that much attention since my open-heart surgery! It was above and beyond. All my issues were addressed.” – CR

“I was very happy with it because it was figured out! I’ve had this for over 10 years, and no one knew what it was. I wish I had this experience years ago.” – MH

“I have been sick for 2 years, going here, going there… this clinic was a total blessing because now I have a diagnosis and I’m eating.” – HB

“One visit met my needs. I would hate the idea of traveling to Phoenix 5 times for separate visits. The swallow test was comprehensive. The surgical remedies were well explained.” – JC

“Both my husband and I were so pleased. I can’t say enough positive things about it. We are so glad the Mayo Clinic has gotten involved in this type of care.” – CS

“It was so incredibly helpful to have all the respected disciplines and points of view talking to me at one time and allowing me to hear their interactions. It was cool.” – TW

PATHWAY TO SUCCESS

It is acknowledged that the majority of SLPs are not experiencing dysphagia care with an integrated multidisciplinary model. This does not mean that your patients are out of luck. You can still provide collaborative care for your patients as well as advance our field in changing the culture of dysphagia care! Starting with a review board is an excellent segway to bringing specialists to one place and proving both the expeditious nature of the MSC and the value of the SLP on a dysphagia team. 

So often, SLPs find themselves as clinical care coordinators because they are the first specialist discovering abnormalities on imaging studies. Ease your burden by building the team around you. Reimbursement for SLP services is challenging (Additional Details on 2023 Medicare Fee Schedule, 2022), but demonstrating our value more within the context of a team could help battle this at a legislative level.

  1. Gather ENT & GI contacts.
    1. For those working in a hospital-based facility and/or urban area, start with affiliated specialties and seek out group leaders.
    2. For those working in more isolated medical facilities (e.g., SNF) and/or rural areas, locate the closest groups in your community or network.
    3. Connect with these specialists on professional social media accounts (e.g., Twitter, Instagram).
  2. Reach out by phone or email.
    1. Introduce yourself, give your background training, share your interest in starting an in-person or virtual multidisciplinary review board for complex dysphagia cases, and invite them to join. 
    2. Describe the barriers you and your patients have encountered by not having multidisciplinary dysphagia care. 
    3. Give specific examples of how the case could have been better managed had there been a team in place. 
  3. Send the official recurring invitation with date, time, and location.
    1. Monthly meetings are often feasible for specialists.
    2. While in-person is always the preferred platform, this is often not easy even for specialists in the same building. Virtual platforms like Zoom and Teams are excellent options.
    3. Popular meeting times are before the first patient of the day or during the lunch hour.
  4. Track patient outcomes.
    1. Data collection is key to administrative buy-in and support for future endeavors. 
    2. This, along with interprofessional collaborations, can spark interest in co-presentations at national conferences and even published work.

If you run into a scenario where a specialist you reach out to is not interested, ask if they can recommend a colleague who may be. 

If you encounter a physician who does not understand why you are interested in the esophagus as part of assessing the entire swallowing continuum, share the following literature: 

  • Poor patient localization with swallowing symptoms: Ashraf et al. (2017), Jones et al. (1985), Roeder et al. (2004), Smith et al. (1998), Wilcox et al. (1995)
  • Protective reflexes of the aerodigestive tract: Allen (2016), Jadcherla (2006), Jadcherla et al. (2010), Shaker (2006)
  • Upstream/downstream behaviors in normal swallowing: Ham et al. (1985), Kunieda et al. (2018), Lever et al. (2007), Mittal (2011), Nekl et al. (2012), O’Rourke et al. (2014)
  • Upstream/downstream effects and/or oropharyngeal and esophageal interrelationships in disordered swallowing: Belafsky et al. (2010), Choi et al. (2003), Gullung et al. (2012), Triadafilopoulos et al (1992), Yuen et al. (2019)
  • Esophageal visualization by the SLP during VFSS: Miles et al. (2015), Reedy et al., (2021)
  • A validated esophageal screening protocol by the SLP (e.g., Robust Esophageal Screening Test: REST): Watts et al. (2019), Watts et al. (2021)

CO-AUTHOR

Dr. Stephanie Watts is an Assistant Professor and clinical Speech Pathologist at the University of South Florida. She earned an undergraduate degree in Speech Pathology at Florida State University then her masters and doctoral degrees in Speech Pathology at USF. Stephanie is a clinician, researcher, and educator specializing in the area of swallowing assessment and treatment. Clinical specialties include evaluation and management of complex swallowing and voice disorders. Her research interests include cough neurophysiology, clinical evaluation of airway protective behaviors, esophageal physiology, and maximizing patient health outcomes through multidisciplinary care. Her research has garnered her several publications and awards. She is active in her professional societies while maintaining teaching efforts within the USF system and across several Universities in Florida.

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