Recently I walked through a speech clinic of the near future. You might expect that the examination rooms of this clinic would be stocked with high-powered flexible endoscopes, that would allow one to see with stunning detail oral, laryngeal and pharyngeal structures. You might also look around for powerful tablets and smartphones and high-fidelity digital audio speakers, to provide crystal clear reproductions of a person’s speech output. Today’s communication sciences and disorders (CSD) professional is rapidly reformatting current practice models, with wholesale changes for third party reimbursement occurring as this blog is written. But instead of the high technology fittings of a large scale speech clinic, this speech clinic of the near future has barely changed, but for shelves that contain a number of prevention products. The CSD professional encounters something new but also something old, when introducing prevention activities into a clinical practice. What is prevention to a CSD professional? How futuristic is the push to include prevention as a CSD product line? Can most CSD practices absorb prevention into their business models?
When the American Speech-Language-Hearing Association (ASHA) advocated for prevention of disorders of communication, cognition and swallowing in its 1987 position paper, a slow-rolling but persistently accelerating snowball had been born. Prevention of communication* disorders, on the one hand, seems a radically divergent activity from traditional clinical practice for many speech-language pathologists and audiologists. “You mean I have to not only work with my patients to help them improve, but I also have to help change the world so I have fewer patients?” Exactly. That’s it. On the other hand, prevention is set firmly within the foundation of ASHA practice patterns. Prevention may in the short term help some in your community forestall the need for treatment. It will also in the long term bring more persons in need to the CSD professional’s door.
With primary prevention, the CSD professional attempts to reduce or eliminate conditions that may bring about a communication disorder. You do this through either altering a person’s susceptibility to a condition (if I am exposed, what are the odds I will stay healthy?), or reducing the degree of exposure (should I simply avoid the risk in order to stay healthy?) that makes you susceptible. An example of altering your susceptibility might be improving your speech breathing, to speak over noise you encounter while working at a busy restaurant. The same restaurant worker may, in turn, reduce exposure by changing her or his work schedule to rest the voice.
Primary prevention appears the most alien of the prevention concepts to CSD professionals. After all, most of us stop considering a new product line when there is no reimbursement for it! And it’s not testing or treatment, but – but – it’s selling or teaching stuff, to people who may not have impairments. Can I teach healthy people things that may head off their becoming disabled? Can I sell things, and keep track of sales taxes? Yes, we can. If we are willing to lurch out of our comfort zones as clinicians, there may be tremendous return on investment with the increased community visibility we gain as health promotion professionals. So, how do we do primary prevention in CSD? What is the stuff of it? What are the outcomes we want?
On the primary prevention shelves of this near future clinic, I saw tools that included:
I. Oral-motor/motor speech:
- Mouth Sounds, by Fred Newman @ $10
- The Speech Choir: With American Ballads and English Poetry for Choral Reading by Marjorie Gullan@ $1 (used)
- C.O. Bigelow Elixir White/Green hair and body wash @ $10
- 1 gallon of distilled water @ $1
- 1-qt Ziploc bag, containing a roll of Life Savers and a dispenser of mint waxed dental floss @ $5
- 1–qt. Ziploc bag, containing a bound supply of 1 doz. sterile tongue depressors @ $5
- Radius model ergonomic garden trowel @ $10
- GAMES magazine: single issue @ $5
VI. Speech and language:
- The New Moosewood Cookbook, by Mollie Katzen @ $10
- Walk Off Weight with Your Pedometer: A Simple 28-Day Pedometer Walking Program, by Jan Small @ $10
Readers should note that the selection of brand name products is purely coincidental by the blogger. Products have neither been trialed prior to this writing, nor are there financial or non-financial relationships between the blogger and any product company. Primary prevention products are chosen for stocking in this clinic of the near future for their relatively low price; their ready availability in the community, and their applicability to the needs of the prevention consumer. Price points are strictly ad hoc at this writing; experienced CSD practitioners will adjust the price point and product selection to a level that their customers will bear.
The sales area for primary prevention has its own entrance from street level, thereby controlling the mixing of regular clinic patients (tertiary prevention consumers) with those shopping for their CSD wellness needs. Adjacent to the sales area is a video viewing room, with four computing devices available to consumers to view demonstrations of each primary prevention product. Reading racks mounted at eye level near the viewing stations, contain fliers and magazines from community services that support and announce wellness activities on community calendars.
Let’s make sure the original questions posed are answered. To wit:
- How do we do primary prevention in CSD?
- What is the stuff of it?
- What are the outcomes we want?
Ideally, primary prevention products and activities bring your customer into your marketplace. You help them stay healthy to function in their communities, so that the probability of their entering the healthcare system to identify and treat impairments is lowered. You do primary prevention through teaching, training, referring, marketing, selling, cooperating and participating in a large network of community and supports and services for your customer. Your collaborators in primary prevention may include office managers; health educators; fitness center trainers; bodyworkers; priests, rabbis, imams and healers; drama and singing and cooking teachers; and all those who work in wellness and health promotion. Outcome measurement may be as simple a function as that of measuring the customer’s changes in both health literacy and patient “activation”, as in the Patient Activation Measure of Hibbard and colleagues. The long-term outcome desired is that community healthcare costs are ratcheted downward. The story of primary prevention in CSD is, again, being written as we walk through this near future clinic. What do you see in the clinic of the future? Time to move into the secondary prevention wing now….
*communication, cognition and swallowing.
Carey Payne, MCD, CCC-SLP, is an SLP in Elmhurst, IL. He knew nothing about speech-language pathology as a profession until he needed it as a client. He was helped at his university’s speech clinic to improve his fluency. He has helped persons of all ages in numerous work settings, for almost thirty years hence. Carey Payne is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders and 13, Swallowing and Swallowing Disorders (Dysphagia).