Kimberly Breeden, MS, OTR/L, Coach,Founding Partner

Is Toileting Really Speech Therapy? An OT Call to Action

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I have been part of a couple of conversations that discussed speech-language pathologists (SLPs) completing toilet transfers and toileting and if that treatment would be in speech therapy's scope of practice.   It has been mentioned that some SLPs have reported that they had been trained in toilet transfers and are completing toileting and toilet transfers as part of addressing cognition.  Again, these are just conversations about occurrences.  I have not observed this myself.

I think these conversations, however, do indicate the need to consider how we as OT practitioners would address this type of situation if we were to encounter it.  There are a lot of factors to consider in this situation, and I feel like many times in these situations, we as OT practitioners may not be in the habit of applying clinical and professional reasoning to this type of situation. Or maybe we as OT practitioners don't feel confident in our reasoning or how we can address these situations without disrupting the interdisciplinary relationships we value.

The conversations I was part of seemed to reflect current trends I see on social media of responding to the affirmative or in opposition to something, it is either acceptable or not, which could tend to provoke a lot of conflict. I feel that if we were to address these types of situations with a curious approach, it may actually strengthen our teams instead of causing tension.  

I think asking lots of questions and verifying information to guide the dialogue would be the most effective approach.  It is important to recognize that there are many factors that must be considered for best practice, safety of clients, scope of practice, compliance with billing, and professional liability.   These are just a few areas that I feel should be considered or questioned in order to make a determination for clinical practice.  
1. It seemed to me in these conversations that no one referred to scopes of practice, official documents, rules and regulations or other guidelines.  What does the national scope of practice for speech therapy state? What does the  practice act and rules and regulations in that particular state allow for the practice of speech therapy?   According to what I found, the American Speech-Language-Hearing Association's Scope of Practice states: "Service delivery areas include all aspects of communication and swallowing and related areas that impact communication and swallowing: speech production, fluency, language, cognition, voice, resonance, feeding, swallowing, and hearing."  The document repeatedly refers to the scope of speech-language pathology in the aspects of communication and swallowing. No where could I find a mention of self-care beyond feeding and eating or addressing cognition out of the scope of communication or swallowing.  No where in the ASHA Scope of Practice did I find any mention of addressing mobility or transfers of any kind.

I might add that the AOTA Occupational Therapy Scope of Practice specifically states that it is within the scope of occupational therapy to address cognitive function in regards to occupational performance (that means all occupations as specified in the Occupational Therapy Practice Framework, 4th Edition) as well as specifically to address self-care and transfers.

2.  I have been practicing 28 years, I can honestly say that toileting is such a familiar task that I do not feel that I have seen sequencing and cognitive deficits impacting toileting very often outside of dementia. It does occur, but not commonly in my experience.  In the case of dementia the client would have to be determined to be appropriate for cognitive training  versus implementing compensatory strategies and aides. My concern would be that it would be an infrequent occurrence where actual cognitive training/retraining was actually clinically indicated.  Is there adequate justification in these cases that these are appropriate interventions? 

3. If it is determined that cognitive training/retraining would be appropriate in the context of toileting , wouldn't the cognitive interventions be only a small part of the task? I would think it should be questioned if it would be appropriate for an SLP to bill for the entire time spent on this activity or only the minutes that the actual cognitive training was provided? I also think that the descriptions of coverage of services would need to be reviewed to determine if speech therapy providing transfer and self-care services would be billable, because again if the payor's speech therapy coverage includes language for cognition only within the scope of communication and language, it may not be billable at all.  It would also have to be confirmed that the time not spent on cognition would be billable. 

4. I think we should consider the statements regarding "being trained" to do toileting and transfers. There was reference to SLPs being trained by physical therapy staff.  Certified nursing assistants, occupational therapy practitioners, nurses, and physical therapy professionals all receive training on transfers and self-care in their educational programs and then have to demonstrate competency in these skills.  Those same professionals also have to demonstrate competency in these areas annually, if a SLP is supposed to be providing clients self-care and transfers services, wouldn't this require completion of formal training for this and then an annual demonstration of competency? What do the state rules and regulations say about competency requirements for self-care provision from professionals whose educational requirements do not include self-care training? If acceptable training was obtained, it would not necessarily qualify an SLP to train clients on transfers and toileting, it would only ensure they are competent in providing non-billable care, like a nursing assistant.  

5. What would the liability be for the facility as well as the SLP? If there were to be an incident while the SLP completed toileting , does the facility feel that this would be covered? Does the SLP want to take a chance of being investigated for addressing an area that is pretty gray and if self-care is not part of their training, could they actually be liable for providing care their license does not cover? 

6. Would this be considered duplication of services or even worse providing inconsistent care for clients? If the SLP is working on cognitive interventions during this task, that indicates a client has cognitive impairments. If OT is addressing all aspects of toileting: cognitive, sensory, behavioral, psychosocial, coordination, ROM and strength, balance, mobility, vision, DME and AE needs and the OT or OTA is providing instruction for strategies in regards to all of these issues aren't we possibly confusing this client by providing potentially different strategies? Is the SLP consulting the OTs and OTAs prior to providing these interventions? 

7. It seems to me that the justification for this as treatment for speech therapy was because they were using the activity for the purpose of cognitive training.  I would point out that the ASHA Scope of Practice does not mention the therapeutic use of activity or occupations for the benefit of cognition, at least not that I could find.  In contrast, the Occupational Therapy Scope of Practice specifically states that occupational therapy interventions include "therapeutic use of occupations and activities".   

I want to commend the efforts of the SLPs who seem to be addressing toileting for the benefit of the clients.  I definitely feel that if the SLP obtains training that meets the state requirements it would be beneficial to the client to provide this care, but I would re-state that providing care does not mean it is "speech therapy".  It does not necessarily qualify the SLP to provide training for toileting or transfers or for the provision of that care to be billable.  I also want to express my respect and appreciation for the profession of speech-language pathology as well as for the speech-language pathologists who provide valuable services to those with communication and swallowing needs. 

I realize that there are many other considerations and questions that should be asked in regards to this type of situation, and I think that is exactly my point.  It is imperative to ask questions, apply clinical reasoning and most importantly verify national and state guidelines regarding practice and reimbursement. I feel that we as healthcare professionals should be applying this type of reasoning to all clinical situations to ensure that practice is not only informed but ethical and legal.  This practice could strengthen our teams by increasing understanding to the value that each discipline brings to the team and protecting one another in regards to liability. 

I was equally concerned that from my perspective I did not hear positions for justifying why OT would be the most qualified to address toileting and actual toilet transfers. It was confusing for me because I frequently see and hear OT practitioners express concerns regarding the recognition of occupational therapy as a profession as well as concerns of encroachment from other disciplines.  To be totally honest, I have these same concerns.  I think this was the perfect opportunity to provide valid information and evidence to support OT's role in addressing the occupation of toileting.  

Although I share the concerns regarding the lack of recognition of OT and encroachment, I feel strongly that these concerns can be addressed and even resolved.  As recent as 2 years ago, I was of the opinion that it was the responsibility of our national and state associations to advocate and protect our profession.  I no longer hold that opinion.  I always say that knowledge is power, so I have worked to become more informed.  I believe that AOTA has developed a strong practice framework and scope of practice that clearly defines occupational therapy and has thoroughly stated the broad scope of services that occupational therapy practitioners are trained to provide.  I see many states that have adopted practice acts that are consistent with AOTA's Model Occupational Therapy Practice Act and Occupational Therapy Scope of Practice.  I see the advocacy that is carried out by AOTA and state occupational therapy associations across the country regarding reimbursement and legislative issues that impact occupational therapy. 

I believe that one of the biggest problems lies within actual occupational therapy practice. We as occupational therapy practitioners are not using these tools and documents and we are failing to question our own scope of practice as well as the scope of practice of other disciplines.  Literature indicates that we, OT practitioners, tend to demonstrate self-limiting behaviors.  I came across a quote from Eleanor Clark Slagle that was stated almost 100 years ago, "Stand up and face them.  Don't hang back."  She could not give us more relevant advice for the times we currently face.  This statement is now ingrained in me.  I believe that we as occupational therapists, occupational therapy assistants, and students can be powerful agents of change in each and every one of our settings if we are willing to ask valid questions in the best interest of patient care and the organizations we serve.  I believe that we can increase recognition of the value that we provide to these organizations by standing up and asking tough questions, starting difficult conversations and most of all verifying information.  

OT practitioners can be most effective when we are informed of the OT scope of practice, practicing at the top of our licenses, facilitating interdisciplinary conversations that explore scopes of practice and most importantly asking tough questions when practice concerns arise.  

As OT Month approaches, I would challenge each OT, OTA and student to consider how you approach situations like this.  Do you rely on explanations given to you?  Do you verify that information?  Do you ask questions specific to scope of practice, billing guidelines and best practices?  I know that I have a lot of work to do in this area myself, so lets challenge ourselves to "stand up and face them"!  Remember, we are better together!  We can make an impact, if each and every one of us took action, we would be impacting every single setting in which OT services are provided.  Now that is food for thought!

Written by Kimberly Breeden, MS, OTR, Instructor, Coach and Founding Partner

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