Developing Clinical Competence to Prepare Clinicians for the Healthcare Environment

Department of Speech-Language Pathology, New York Medical College

Division of Speech-Language Pathology, Children’s & Women’s Physicians of Westchester

Who We Are

Kate Franklin Chair & Associate Professor of Clinical Speech Language ‐Pathology

Kathleen KaiserDirector of Clinical Education & Assistant Professor of Clinical Speech-Language Pathology

Barbara LeaderAssistant Professor of Clinical Speech-Language Pathology

Goals of Today’s Talk

Review development and modification of the curriculum

Discuss specialized diagnostic practica experiences

Discuss internal and external placement considerations

Next steps

History of the Program

Relatively new program

Purposeful focus on development of academic and clinical opportunities to promote student success in a healthcare environment.

Key Points About the Academic Curriculum

No electives

Always responsive to trends and feedback from constituents (employers, graduates, clinical educators in the field)

Academic Curriculum

Preparation for Specialization

Neuroscience (Year 1/Term 1)

Neurophysiology Neuroanatomy Cerebrovascular

System/Ventricles/CSF Neuroimaging Sensory Pathways Motor Systems Cranial Nerves Visual Systems Auditory/Vestibular Systems Axial-Limbic Brain Cerebral Cortex & “Higher” Cortical

Functions

SETS THE STAGE FOR

• Advanced Anatomy (with cadaver dissection)• Dysphagia sequence• Speech Science• Voice Disorders• Neuromotor Speech Disorders• Adult Neurogenic Disorders• Management of TBI and Right Hemisphere Dysfunction

Advanced Anatomy of the Speech and Hearing Mechanisms (Year 1/Term 2)

Thoracic Wall and VisceraMediastinumAbdominal Wall and VisceraHead/Neck/FaceSkull and Cranial NervesRoot of NeckOral and Nasal CavitiesPharynxLarynx

SETS THE STAGE FOR

• Dysphagia sequence• Speech Science• Voice Disorders• Neuromotor Speech Disorders• Adult Neurogenic Disorders• Management of TBI and Right Hemisphere Dysfunction

Bioinstrumentation Course (Multiterm Course)

VisipitchElectroglottographSound Level MeterDry SpirometerPhonatory Aerodynamic SystemDigital Swallow

Workstation

SETS THE STAGE FOR

• Dysphagia sequence

• Speech Science

• Voice Disorders

• Neuromotor Speech Disorders

Dysphagia Pediatric Dysphagia

Adult and pediatric swallow physiology and related disorders

Clinical and instrumental diagnostic techniques

CLINICAL OPPORTUNITIES

Adults• Clinical bedside exams• Instrumental exams• Treatment

Pediatrics• Outpatient evaluation• Review/interpretation instrumental exam• Treatment

The Modified Barium Swallow Impairment Profile: MBSImP™ Standardized Training and Reliability Testing (Bonnie Martin-Harris)

Adult Neurogenic Disorders

Neuromotor Speech Disorders

Neurogenic Language Disorders

Management of TBI and Right Hemisphere Dysfunction

CLINICAL OPPORTUNITIES

Bedside speech/cognitive/linguistic evaluation

Outpatient evaluation and treatment

Management of Medical Patients(Multiterm Course)

ICU / Traches & Vents Monitors/equipment Respiratory support Tracheostomy tubes

Head/Neck Cancer Speaking valves Esophageal speech TEP Artificial larynges

Documentation EMR

CLINICAL OPPORTUNITIES

Medical placement

Specialized diagnostic practica

**Clinical Skills Lab**

Clinical Experience

Preparation and Sequencing

Clinical Experience

Internal Practicum Experience: 2 Semesters (Fall, Spring)

External Practicum Experience: 3 Semesters (Summer, Fall

Spring)

Clinical Skills Lab

Behavioral Health Center

Westchester Institute for Human

Development (WIHD)

NYMC Academic Building

Maria Fareri Children’s Hospital

Westchester Medical Center Main Hospital

Faculty Practice Clinic/CWPW

Acute Rehab Unit

Clinical Experience: Internal I +II

Clinical Affiliation with New York Methodist Hospital

Clinical Experience: Internal I + II

Faculty Practice/CWPW

Outpatient diagnostics (Peds. and Adults)Speech, Language, Feeding

Outpatient therapySpeech, Language, Feeding

Weekly Aphasia GroupInpatient diagnostics (WMC

main hospital)Cognitive-Linguistic Evaluations for

newly admitted patients

Westchester Institute for Human Development (WIHD)

Outpatient diagnostics (Peds. and Adults)Speech, Language, Feeding

Outpatient therapySpeech, Language, Feeding, Aural

rehabInpatient experience at

Behavioral Health CenterPediatric and Adolescent units Informal diagnosticsWeekly therapy sessions

Clinical Experience: Internal I

6 days of intensive classroom instruction prior to beginning clinic

The Beginning: “Clinic Boot Camp”

Clinical Experience: Boot Camp

• General Clinic Information:• Infection Control• Patient Confidentiality• HIPAA• Presenting yourself as a Professional: Dress Code

• Important ASHA Documents• Certification Standards• Supervision of Student Clinicians• Scope of Practice• Code of Ethics

• Documentation of Clinical Activities (observation hours, clinical hours., etc.)

Sample Day:

Clinical Experience: Internal I +II

Half-semester rotation; students sign-up for half-days

Students work in groups of 4 under certified audiologistsAudiology EvaluationsHearing Aid FittingsIncludes screenings of newborns at Maria Fareri Children’s

Hospital (well-baby and NICU)

Audiology:Westchester Institute for Human Development

Speech and Hearing Center

Clinical Experience: Internal I +II

• Half-semester rotation; approximately 6 consecutive Fridays

• Students work in groups of 4 under supervision of NYMH SLP Staff

• Bedside evaluations for new consults (approx. 2-3/day)

Diagnostic Practicum – Hospital RotationCenter for Swallowing and Speech-Language Pathology

New York Methodist Hospital (Brooklyn, NY)

Clinical Experience: NYMH

• Preparation:• 2 hour in-class preparation program focusing on:• Role of SLP in acute care settings• Understanding the different types of medical unit (e.g., ICU, CCU,

Acute Rehab)• Types of Dysarthria• Understanding of Apraxia: speech, oral, limb• Types of Aphasia• Right hemisphere impairment• TBI/Cognitive-linguistic disorders• Dementias• Use of medical abbreviations

Hospital Rotation@ NYMH

Clinical Experience: NYMH

• Training in Assessments:• Oral-Mechanism Evaluations• Evaluation of Swallowing; normal swallow physiology;

assessment techniques

• Sample reports are provided

Hospital Rotation@ NYMH

Clinical Experience: NYMH

• Goals of the rotation:• Learning how to interact with adult patients• Learning how to review EMR• Lab results• Radiology reports: MRI, CT, etc.

• Writing hospital-based reports under supervision• Results of assessment are discussed as a group• Each student individually writes reports; written feedback is

provided• Supervising SLP enters report in EMR

Hospital Rotation@ NYMH

Clinical Experience: NYMH

• 100% supervision for each encounter (approx 15 mins.)• In team format, the 4 students evaluate at bedside:• Structure and function of oral mechanism• Language/Cognition• Orientation, simple and complex yes/no questions, following

commands, picture description, repetition, automatic speech, divergent semantic thinking

• Swallowing• Speech production (voice, articulation, fluency, resonance)

Hospital Rotation@ NYMH

Clinical Experience: NYMH

• In the group setting, each student participates in self-reflection activities regarding their clinical performance:

• What went well

• What could be improved upon next time•

Hospital Rotation@ NYMH

Clinical Experience: NYMH

• Additionally:• All students observe MBS study in radiology department

(first semester students have an additional opportunity during second semester, as part of the Dysphagia class)

Hospital Rotation@ NYMH

Clinical Experience: Internal II

• Second semester program

• Each student participates on 2 Fridays in teams of 2

• Evaluation procedures (formal and informal):• Language Screening • Speech Screening• Hearing Screening

• Written report generated for all screenings, with recommendation to parents for full speech-language evaluation, when appropriate

Community Preschool Screenings

Clinical Experience: External I, II, III

All students participate in 3 externships:

Experiences across the lifespan (EI through geriatric)

At least one externship will be in a medical setting

Students are encouraged to pursue NYS SLP teaching certificate (TSSLD); one externship will be in a school setting

Next Steps

Challenges and

Opportunities

Next Steps: Challenges

Prepare students for ever-changing landscape of healthcare

“We have to move out of our traditional comfort zones to network and collaborate more routinely and comprehensively with colleagues in other disciplines…It requires consistent use of evidence-based practice. It requires thoughtful consideration of a patient’s functional status or a student’s academic status…It perhaps requires some tolerance for short-term ambiguity…”

Elizabeth McCrea, ASHA Leader June 2014

Next Steps: Challenges

Adjust for continuing staff reductions in medical settings

1. Issues regarding productivity2. Changes in regulations3. Decreased funding/reimbursement

Result in reductions in availability of supervisors

Next Steps: Challenges

Impact of Affordable Care Act

Predicted outcomesTeam-based patient careImproved collaborationEnhanced quality

New reimbursement modelspay for performance [outcomes]value-based purchasingaccountable care organizations

Next Steps: ResponsesMove Out of Practice Silos

Interprofessional Education [IPE] AND

Interprofessional Practice [IPP]

“The emphasis of IPE in health care is a result of the growing evidence of the benefits of IPP in health service provision”

Zraick, Harten, Hagstrom SIG 10 Perspectives

Next Steps: ResponsesMove Out of Practice Silos

LCME: Liaison Committee on Medical EducationAccreditation Standard ED-19-A

“The core curriculum of a medical education program must prepare medical students to function collaboratively on health care teams that include other health professionals. Members of the health care teams from other health professions may be either students or practitioners.”

Next Steps: ResponsesMove Out of Practice Silos

Barriers to IPE

1. Financial support2. Differences in academic schedules3. Different program structures4. Changes in work culture

Goldberg & Koontz, 2014

Next Steps: ResponsesMove Out of Practice Silos

Challenges in implementing IPE/IPP in CSD:

1. Adding coursework or clinical requirements

2. Lack of administrative support for IPE and IPP efforts and/or administrative processes for recognizing IPE/IPP efforts made by faculty

3. Lack of faculty adequately prepared to teach IPE/IPP

Zraick, Harten, Hagstrom 2014

Next Steps: Institutional Responses

1. Broad IPE initiative across all Touro campuses and programs2. Specific initiative across metro NY campuses3. Specific activities on NYMC campus

team building, shared courses, simulation/standardized patientsNY Med Talks

Next Steps: NYMC Responses

CLINICAL SKILLS LAB – new on-campus facilitySTANDARDIZED PATIENTS

Simulation: trained participants replicate real health scenarios

Patient protocols under development

Allow for joint assessment by PT, medical students

Next Steps: NYMC Responses

Protocols for STANDARDIZED PATIENTS at Clinical Skills Lab

Pediatrics: parent interview for pre-planned diagnoses, including parental-report screening toolsAdults: patient interview oral mechanism exam

cognitive-linguistic testing bedside swallow exam

All: post-evaluation counseling

Next Steps: SHSP Responses

School of Health Sciences and Practice at NYMC Physical Therapy Disaster Medicine Environmental Health Science Epidemiology and Community Health Biostatistics Health Policy and Management Speech-Language Pathology

Next Steps: Departmental Responses

Our department is positioned so these challenges are manageable:Strong administrative support from SHSP and NYMC

facilitated by recent changes in medical college administration – promoting IPE

Faculty within SHSP is ready and willing to collaborateFlexibility to adapt coursesCapstone experiences

Next Steps: Goals for Faculty

Identify opportunities for IPE and IPP within academic and clinical specialty areas

Participate in development of standardized patient protocols

Identify possibilities for input from other SHSP departments

Infuse concepts of IPE and IPP into coursework

Next Steps: Goals for Students

IPEBroadens perspectives regarding patient needsReduces territoriality and sense of encroachmentFosters respect for contributions of other professions

to patient careLearn/understand pressures facing other professions

Next Steps: Goals for Students

Clinical Skills Lab and standardized patients will serve to:Address gaps in clinical experiences based on

differences in caseload, cancellations/no-shows, placements…Diagnostic protocolsCounseling opportunities

Assess clinical competencies with standards developed across semesters

Assure consistency of experiences across studentsProvide practical experience in team-based work

Resources Advisory Committee on Interdisciplinary, Community-Based Linkages October 2014.

Transforming Interprofessional Health Education and Practice: Moving Learners from the campus to the community to improve population health. Thirteenth Annual Report to the Secretary of the United States Dept. of Health and Human Services and the Congress of the United States.

Goldberg, L. Koontz, J. , October 2014. Interprofessional case-based problem-solving: learning form the CLARION Experience. SIG 10 Perspectives on Issues in Higher Education, Vol. 17, 47-55. doi:10.1044/aihe17.2.47

McCrea, E. June 2014. Wanted: a community of leaders. The ASHA Leader, Vol. 19, 6-7

Zraick, R. Use of standardized patients in CSD. ASHA Website. Retrieved from www.asha.org

Zraick, R., Harten, A., Hagstrom, F. October 2014. Interprofessional education and practice: a primer for training future clinicians. SIG 10 Perspectives on Issues in Higher Education, Vol.17, 39-46. doi:10.1044/aihe17.2.39

Thank You

Contact Information

Department of Speech-Language Pathology213 School of Health Sciences and Practice

New York Medical CollegeValhalla, NY 10595 (914) 594-4239

SLP_SHSP@nymc.edu

Division of Speech-Language PathologyChildren’s & Women’s Physicians of Westchester

(914) 594-4912