NeuroRehabilitation ELSEVIER
NeuroRehabilitation 8 (1997) 43-48
The speech-language pathologist on the cognitive rehabilitation team: current training and practice issues Judith Iacarino Mary/and NeuroRehab Center Inc., 15 East Main Street, Suite 220 Westminster, Mary/and 21157, USA
Abstract Cognitive rehabilitation has been provided by a diverse group of professionals, raising the questions of 'boundaries' in provision of services. In this era of managed care and accountability, appropriate distinctions must be made relative to skill sets specific to disciplines. Current training guidelines and proposed future guidelines are presented, as well as suggested practice boundaries for the speech-language pathologist. Proposed changes in treatment delivery are also discussed. Copyright © 1997 Elsevier Science Ireland Ltd.
Keywords: Cognitive rehabilitation; Cognitive-communication impairment
1. Introduction
2. Current training guidelines
Historically, many disciplines have participated in the treatment of cognitive impairments, although there has never been a systematic structuring of a coordinated approach. Rather, for the most part, each profession has attempted to solve the puzzle from their own unique perspective. As the multi-disciplinary team prevails in rehabilitation centers, one must assume that, to some degree, lines are drawn in the sand, and the task is divided accordingly. This article is an effort to clarify these boundaries, so that providers of service to the cognitively impaired may increase cooperative efforts with the common goal of maximizing outcomes.
To practice in speech-language pathology, an individual must successfully complete a training program to the Master's degree, which incllides coursework in normal and disordered communication, and clinical practicum primarily at the graduate level. Practicum requirements mandate working in a variety of facilities with children and adult populations. The final pre-requisite for achieving certification from the American Speech-Language-Hearing Association, the national certifying organization, is the successful completion of the national qualifying examination. Undergraduate curriculum provides the foun-
1053-8135/97/$17.00 Copyright © 1997 Elsevier Science Ireland Ltd. All rights reserved
PIIS1053-8135(96)00207-7
44
J. lacarino / NeuroRehabilitation 8 (J997) 43-48
dation for understanding of communication with a broad-based education in all areas of normal development. In this context, the concept of cognition is interwoven throughout the coursework in the introductOIY courses of speech and language development, to foster an awareness of normal cognitive development in the child. In uppel; level graduate courses, cognition is studied again, this time in relation to the communication impairments prevalent in adult neuropathologies. Beyond this, training predominantly occurs in the practicum experiences. Off-campus practica provide practical instruction in treatment of cognitive-communication impairments in a variety of sites. More specifically, practicum hours are distributed between speech and language, and adults and children. To the extent that training in cognitive rehabilitation is addressed, it would meet the requirements in the category of language remediation in both children or adults. Typical sites for internships include hospitals, outpatient clinics, day treatment programs, and schools. Since the inception of the profession of speech-language pathology in 1925, there has been an explosion of information. Within the period of time it takes to acquire a Master's degree, the student has always been required to accumulate the knowledge necessary for work in any setting. It has become apparent that this is no longer possible given the vast amounts of information becoming available. Henri [1] recognized that, with the increasing demand for timely positive outcomes, students cannot afford to rely on 'on the job' training to improve their clinical skills. This has prompted his recCimmendation for specialization within the graduate program, as well as other suggestions, including competency enhancement and inter-university collaborations. The need for specialists has also become evident within the profession as well. This is being addressed in two ways. First, in recent years special interest divisions had been established in ASHA to allow individuals to pursue topics of interest with other professionals. Also, much discussion regarding specialty recognition has been taking place. The purpose of this is to give speech-language pathologists an opportunity to develop greater qualifications in an area of inter-
est, and provide for the consumers a database of professionals who have expertise in a given domain. Additionally, to remain current in selected topics, continuing education is currently being provided nationwide, and will remain a very important facet of professional life. 21. Future training guidelines
As specializing within the profession becomes a reality, consideration must be given to a proposed training program in cognitive rehabilitation. To successfully prepare for a career in cognitive rehabilitation in speech-language pathology, a program should have three facets: 2.1.1. Phase one
The initial phase would encompass normal cognition through the lifespan, and providing a detailed understanding of the development and progress of the interaction of language and cognition as a dynamic process. Further, academic training in human neuroanatomy and neurophysiology in children and adults is a critical component of this section.
2.1.2 Phase two
The second phase provides instruction in neurologic disorders, including etiologies, behavioral manifestations of organicity, and effects on speech, and cognitive-linguistic communication skills.
21.3. Phase three
Finally, the third facet would combine the didactic aspects with additional instruction in intervention techniques, and, the culmination of the program, clinical practicum for training in application of these techniques. The clinical aspect would be a highly structured organization of cooperating hospitals and other rehab facilities who train speech-language pathologists, neuropsychologists and occupational therapists in the multi-disciplinary team milieu to coordinate their efforts in cognitive rehabilitation. Initiating collaboration among disciplines at the student level educates that group in the team process in addition to merely addressing actual
J. lacarino / NeuroRehabilitation 8 (1997) 43-48
strategies for intervention. Each student acquires increased awareness of the concept of and participation on the interdisciplinary team, and their role within it. This type of program establishes a strong academic foundation in concert with intensive clinical instruction in a team process environment for optimal benefit of future consumers. 3. Practice boundaries The American Speech-Language-Hearing Association (ASHA) [2] has recently revised the scope of practice in speech-language pathology to establish current practices consistent with the changing healthcare and education environments. As in any profession, speech· language pathology is dynamic and continues to be proactive in developing practice parameters, while maintaining its' position on the multi-disciplinary team. Responsibilities include prevention, screening, assessment, diagnosis, treatment, consultation and counselling relative to speech, voice, language, communication, swallowing and related disabilities. Where necessary, speech-language pathologists provide services supporting the use of augmentative and alternative communication devices and other communication prostheses and assistive devices. More specifically, practice in speech-language pathology includes among other things, the diagnosis and treatment of language (including the components of phonology, morphology, syntax, semantics, and pragmatics, and including disorders of receptive and expressive communication in oral, written, graphic, and manual modalities); and cognitive aspects of communication (including communication disability and other functional disabilities associated with cognitive impairment) [3]. Therefore, recognizing the relationship that exists between language and cognition, and acknowledging that individuals exhibiting language impairments are very likely to also exhibit cognitive impairments, 'the speech-language pathologist assumes responsibility for thorough and flexible exploration of relations between cognitive deficits and their possible communicative consequences and also between communicative deficits and their possible cognitive bases' [2].
45
Affirming this relationship, the Committee on Language of the American Speech-LanguageHearing Association has identified a new classification of disorder: cognitive-communicative impairments, those impairments of communication related to impairments of non-linguistic cognitive functions (e.g. attention, perception, memory) [4]. Further, noting that the acquisition of knowledge is a language· mediated experience, the sub-committee on Language and Cognition of ASHA, in 1987 acknowledged the interaction of the two, and identified cognitive impairments which may affect language, including impaired attention, perception and/or memory; inflexibility, impulsivity, and/or disorganized thinking or acting; inefficient processing of information; difficulty processing abstract information; difficulty learning new information, rules, and procedures; inefficient retrieval of old or stored information; ineffective problem solving and judgment; inappropriate or unconventional social behavior; and impaired executive and metacognitive functions: self-awareness of strengths and weaknesses, goal setting, planning, self-initiating, self-inhibiting, self-monitoring, self-evaluating [5]. Hagen [6] has stated that, a cognitive impairment can be manifested in linguistic impairments as well, so that a result of the breakdown of well-structured mental processes is also represented by: • • • • • •
decreased auditory and reading comprehension; expressive language which does not make sense to the listener; tangential language, completely irrelevant to the topic; inability to inhibit verbal expression; inappropriate word order and/or grammar; inability to recall specific words.
With this in mind, the speech-language pathologist approaches the patient assessment as a dynamic process of information gathering with regard to (1) the patient's ability to effectively use all forms of language in a variety of environments; and (2) determining which and to what extent cognitive processes are impaired.
46
J. lacarino / NeuroRehabilitation 8 (1997) 43-48
Although there is great value to the use of formal measures with traumatic brain injury patients, it can never be considered the last word for providing diagnostic information to the team. Ylvisaker and Szekeres [7] consider assessment as a form of hypothesis testing regarding the patient's strengths and weaknesses. These hypotheses are then accepted or rejected based upon record reviews, family interviews, formal tests, informal tasks, and, finally, diagnostic treatment. Intervention strategies vary greatly, depending on many factors, including overall cognitive abilities, specific cognitive impairments, and length of time post-injury. Certain strategies frequently used are: •
• • •
•
Environmental manipulation: changing the environment in some way to simplify tasks for the patient (e.g. placing a schedule in the same location so it can be easily located). Training task specific routines: teaching the procedures necessary to accomplish a particular task. Attention process training: systematically increasing the amount of time one is successfully able to attend and complete a task. Compensatory strategies: using additional methods of remembering, such as log books, chunking numbers, mnemonics, cognitive devices. Metacognitive strategies: training patients to question their behaviors toward successful completion of a task or activity [6-9].
'The loss of social grace is perhaps the most devastating thing that most clients face after head injury' [8]. The arena of 'social skills' presents a classic example of the interaction of language and cognition, with cognitive skills such as orientation, attention/concentration, memory, organization and problem solving/judgment serving as the basic underpinnings for the successful communication interaction [10]. Given the resulting high occurrence of deficits in social discourse, its' direct impact on all daily interpersonal activities, and its' direct effect on long term success, it is an area of major importance for the speech-language pathologist. Again,
intervention varies, but includes cogmtlve and meata-cognitive training of appropriate social skills. A final stage is transfer and maintenance of these behaviors to other environments where they can be practiced. In the long recovery process the role of social discourse increases dramatically in importance as the individual returns to the community. 4. Future practice guidelines At the current rate, by the year 2050, 100% of the gross national product, will be dedicated to healthcare [11]. Clearly, new and creative strategies must be implemented for provision of rehabilitation services. Two criteria must be met in this process, however: technical excellence in the form of innovative treatment for cognitive rehabilitation; and a cost effective environment. As we explore these challenges, it becomes evident that current practices may not meet those criteria as efficiently as possible. With this trend in effect, we as Ph.D. and Master's level speech-language pathologists will more frequently find ourselves in the role of consultant/supervisor, and less often as direct service provider, so the salary dollars can be stretched. In this section, we will explore these options for future opportunities. A strategy which has been employed in other disciplines and is re-emerging as a viable option in speech-language pathology, is the use of support personnel in a variety of capacities. The 1994 Task Force of Support Personnel [12] has endorsed this concept in a position statement, and presented a series of guidelines of responsibilities for the speech-language pathology assistant, as well as for the speech-language pathologists who will assume the supervisory role. Accordingly, the American Speech-Language- Hearing Association has passed this resolution at the 1996 session of the Legislative Council, making this an official position of ASHA. Although guidelines were originally established by ASHA in 1981, the current specifications are more stringent, in that the present criteria require an associate of arts degree or equivalent, clinical practicum hours, and successful completion of a national examination, all leading to a certification. Each state may establish a
J. Iacarino / NeuroRehabilitation 8 (1997) 43-48
license. As these are more demanding than the original prerequisites, the responsibilities are greater. Essentially, speech-language pathology assistants may conduct screenings, provide treatment assistance or direct treatment when following a prepared treatment plan, assist in assessment, assist with documentation, schedule, and participate in research projects, in-service training and public relations programs. Under this structure, the speech-language pathologist still retains the legal and ethical responsibilities for all assistants providing care under her supervision [13,14), Additionally, speech-language pathology aides are currently being utilized in various settings. As credentials have not yet been established nationwide, and there are currently no criteria for their training, they are usually trained on-site to work with a very specific population, and have an extremely restricted role in provision of services. However, to the extent that they may allow the speech-language pathologist increased direct treatment time by preparing materials or equipment, they are extremely helpful. A variation on this theme is the rehabilitation aide, who serves as an attendant for all disciplines (OT, PT, and Speech) where needed. The key factor is the individual with an understanding of rehabilitation concepts who becomes a motivated participant in the process of maximizing patient success. From the cognitive rehabilitation perspective, there will be a multi-level system of individuals created with varying degrees of expertise in speech-language pathology, essentially developing a team of providers. Although this difference in qualifications exists, in essence, training in rehabilitation concepts for everyone regardless of level of personnel maximizes the potential for that facility to provide successful outcomes. Another proposed alternative for provision of services utilizes the model of a single individual who is cross-trained to supply treatment in more than one discipline. This is the concept of multiskilling. This has been recognized by some as the optimal solution for maximizing the healthcare dollar [3]. In contrast to supplementing healthcare professionals with support personnel, the one choice in the concept of multi-skilling sug-
47
gests that professionals may expand their scopes of practice to increase the amount of services one is able to provide. These services may include basic patient care, clinical or administrative skills. Pietranton and Lynch [11] report that multiskilling, although not new, is having a resurgence in popularity because it is viewed by many as the best option for positioning healthcare for the future. For as many individuals who feel that this is the solution, an equal number fear this choice as the downfall of high quality services. Although it can be viewed by some as a particularly cost effective way to provide a multitude of services, multi-skilling may present a new. danger: the treating of patients by individuals who are, in essence, 'jacks-of-all-trades, masters of none', possibly compromising the quality of service. The evolution of this job title remains to be seen. To date, it has only been loosely defined, and may have the potential to offer many alternatives for health-related careers, from professionals to non-professionals. Undoubtedly, it is an unusual twist on current training practices for healthcare professionals, however, the ad hoc committee on multi-skilling of ASHA has pointed out that practitioners have already begun the move toward expanding practices, with speech-language pathologists treating swallowing disorders as an example [13]. In summary, the evolution of rehabilitation professionals has only begun. Driven by managed care and other alterations in reimbursement, the conclusion of this century should see a major reorganization in the provision of services. It is essential that throughout this restructuring, priorities remain clear, specifically the maximal outcomes for the consumers of our services. To this end, increased interaction and shared information among disciplines is paramount. How this is accomplished presents options for innovative progress in rehabilitation for the future. References [1]
Henri B. Graduate student preparation: tomorrow's challenge. ASHA 1994;36(1):43-46. [2] American Speech-Language-Hearing Association. Role of Speech-Language Pathologists in Habilitation and
48
[3]
[4]
[5]
[6]
[7]
J. lacarino / NeuroRehabilitation 8 (J997) 43-48
Rehabilitation of Cognitively Impaired Individuals, ASHA Desk Reference, Vol. 3, 1987. American Speech-Language-Hearing Association. Technical report of the ad hoc committee on multiskilling. ASHA 1996;38(Suppl. 16):53-61. American Speech-Language-Hearing Association. Guidelines for speech-language pathologisis serving persons with language, socio-communicative and/or cognitive-communicative impairments. ASHA 1991 ;33(Suppl. 5):21-28. American Speech-Language-Hearing Association. Role of Speech-Language Pathologists in Habilitation and Rehabilitation of Cognitively Impaired Individuals, ASHA Desk Reference, Vol. 3, 1987. Hagen C. Language disorders in head trauma. In: Costello J and Holland A, eds. Handbook of Speech and Language Disorders. San Diego, CA: College Hill Press 1996;1011-1012 Ylvisaker M, Szekeres S. Management of the patient with closed head injury. In: Chapey R, ed. Language Intervention Strategies in Adult Aphasia. Baltimore,
[8] [9]
[10]
[11] [12]
[13]
[t4]
MD: Williams and Wilkins, 1986. Parente R, Herrman OJ. Retraining Cognition. Gaithersburg, MD: Aspen Publishers, 1996. Sohlberg M, Mateer K, Stuss D. Contemporary approaches to the management of executive control dysfunction. J Head Trauma Rehabil 1993;8(1):45-58. Halper A, Cherney L, Miller T. Clinical management of communication problems in adults with traumatic brain injury. Gaithersburg, MD: Aspen Publishers, 1991. Pietranton A, Lynch C. Multiskilling: a renaissance or a dark age? ASHA 1995;33(6/7):37-40. American Speech-language-Hearing Association. Guidelines for the training, credentialing, use, and supervision of speech-language pathology assistants. ASHA 1996;38(Suppl. 16):21-34. American Speech-Language-Hearing Association. Scope of practice in speech-language pathology: ASHA 1996;38(Suppl. 16): 16-20. Rabins A. Asha publishes SLP assistants guidelines. A.~ha Leader 1995;1(9):1,6.
NeuroRehabilitation 8 (1997) 43-48
The speech-language pathologist on the cognitive rehabilitation team: current training and practice issues Judith Iacarino Mary/and NeuroRehab Center Inc., 15 East Main Street, Suite 220 Westminster, Mary/and 21157, USA
Abstract Cognitive rehabilitation has been provided by a diverse group of professionals, raising the questions of 'boundaries' in provision of services. In this era of managed care and accountability, appropriate distinctions must be made relative to skill sets specific to disciplines. Current training guidelines and proposed future guidelines are presented, as well as suggested practice boundaries for the speech-language pathologist. Proposed changes in treatment delivery are also discussed. Copyright © 1997 Elsevier Science Ireland Ltd.
Keywords: Cognitive rehabilitation; Cognitive-communication impairment
1. Introduction
2. Current training guidelines
Historically, many disciplines have participated in the treatment of cognitive impairments, although there has never been a systematic structuring of a coordinated approach. Rather, for the most part, each profession has attempted to solve the puzzle from their own unique perspective. As the multi-disciplinary team prevails in rehabilitation centers, one must assume that, to some degree, lines are drawn in the sand, and the task is divided accordingly. This article is an effort to clarify these boundaries, so that providers of service to the cognitively impaired may increase cooperative efforts with the common goal of maximizing outcomes.
To practice in speech-language pathology, an individual must successfully complete a training program to the Master's degree, which incllides coursework in normal and disordered communication, and clinical practicum primarily at the graduate level. Practicum requirements mandate working in a variety of facilities with children and adult populations. The final pre-requisite for achieving certification from the American Speech-Language-Hearing Association, the national certifying organization, is the successful completion of the national qualifying examination. Undergraduate curriculum provides the foun-
1053-8135/97/$17.00 Copyright © 1997 Elsevier Science Ireland Ltd. All rights reserved
PIIS1053-8135(96)00207-7
44
J. lacarino / NeuroRehabilitation 8 (J997) 43-48
dation for understanding of communication with a broad-based education in all areas of normal development. In this context, the concept of cognition is interwoven throughout the coursework in the introductOIY courses of speech and language development, to foster an awareness of normal cognitive development in the child. In uppel; level graduate courses, cognition is studied again, this time in relation to the communication impairments prevalent in adult neuropathologies. Beyond this, training predominantly occurs in the practicum experiences. Off-campus practica provide practical instruction in treatment of cognitive-communication impairments in a variety of sites. More specifically, practicum hours are distributed between speech and language, and adults and children. To the extent that training in cognitive rehabilitation is addressed, it would meet the requirements in the category of language remediation in both children or adults. Typical sites for internships include hospitals, outpatient clinics, day treatment programs, and schools. Since the inception of the profession of speech-language pathology in 1925, there has been an explosion of information. Within the period of time it takes to acquire a Master's degree, the student has always been required to accumulate the knowledge necessary for work in any setting. It has become apparent that this is no longer possible given the vast amounts of information becoming available. Henri [1] recognized that, with the increasing demand for timely positive outcomes, students cannot afford to rely on 'on the job' training to improve their clinical skills. This has prompted his recCimmendation for specialization within the graduate program, as well as other suggestions, including competency enhancement and inter-university collaborations. The need for specialists has also become evident within the profession as well. This is being addressed in two ways. First, in recent years special interest divisions had been established in ASHA to allow individuals to pursue topics of interest with other professionals. Also, much discussion regarding specialty recognition has been taking place. The purpose of this is to give speech-language pathologists an opportunity to develop greater qualifications in an area of inter-
est, and provide for the consumers a database of professionals who have expertise in a given domain. Additionally, to remain current in selected topics, continuing education is currently being provided nationwide, and will remain a very important facet of professional life. 21. Future training guidelines
As specializing within the profession becomes a reality, consideration must be given to a proposed training program in cognitive rehabilitation. To successfully prepare for a career in cognitive rehabilitation in speech-language pathology, a program should have three facets: 2.1.1. Phase one
The initial phase would encompass normal cognition through the lifespan, and providing a detailed understanding of the development and progress of the interaction of language and cognition as a dynamic process. Further, academic training in human neuroanatomy and neurophysiology in children and adults is a critical component of this section.
2.1.2 Phase two
The second phase provides instruction in neurologic disorders, including etiologies, behavioral manifestations of organicity, and effects on speech, and cognitive-linguistic communication skills.
21.3. Phase three
Finally, the third facet would combine the didactic aspects with additional instruction in intervention techniques, and, the culmination of the program, clinical practicum for training in application of these techniques. The clinical aspect would be a highly structured organization of cooperating hospitals and other rehab facilities who train speech-language pathologists, neuropsychologists and occupational therapists in the multi-disciplinary team milieu to coordinate their efforts in cognitive rehabilitation. Initiating collaboration among disciplines at the student level educates that group in the team process in addition to merely addressing actual
J. lacarino / NeuroRehabilitation 8 (1997) 43-48
strategies for intervention. Each student acquires increased awareness of the concept of and participation on the interdisciplinary team, and their role within it. This type of program establishes a strong academic foundation in concert with intensive clinical instruction in a team process environment for optimal benefit of future consumers. 3. Practice boundaries The American Speech-Language-Hearing Association (ASHA) [2] has recently revised the scope of practice in speech-language pathology to establish current practices consistent with the changing healthcare and education environments. As in any profession, speech· language pathology is dynamic and continues to be proactive in developing practice parameters, while maintaining its' position on the multi-disciplinary team. Responsibilities include prevention, screening, assessment, diagnosis, treatment, consultation and counselling relative to speech, voice, language, communication, swallowing and related disabilities. Where necessary, speech-language pathologists provide services supporting the use of augmentative and alternative communication devices and other communication prostheses and assistive devices. More specifically, practice in speech-language pathology includes among other things, the diagnosis and treatment of language (including the components of phonology, morphology, syntax, semantics, and pragmatics, and including disorders of receptive and expressive communication in oral, written, graphic, and manual modalities); and cognitive aspects of communication (including communication disability and other functional disabilities associated with cognitive impairment) [3]. Therefore, recognizing the relationship that exists between language and cognition, and acknowledging that individuals exhibiting language impairments are very likely to also exhibit cognitive impairments, 'the speech-language pathologist assumes responsibility for thorough and flexible exploration of relations between cognitive deficits and their possible communicative consequences and also between communicative deficits and their possible cognitive bases' [2].
45
Affirming this relationship, the Committee on Language of the American Speech-LanguageHearing Association has identified a new classification of disorder: cognitive-communicative impairments, those impairments of communication related to impairments of non-linguistic cognitive functions (e.g. attention, perception, memory) [4]. Further, noting that the acquisition of knowledge is a language· mediated experience, the sub-committee on Language and Cognition of ASHA, in 1987 acknowledged the interaction of the two, and identified cognitive impairments which may affect language, including impaired attention, perception and/or memory; inflexibility, impulsivity, and/or disorganized thinking or acting; inefficient processing of information; difficulty processing abstract information; difficulty learning new information, rules, and procedures; inefficient retrieval of old or stored information; ineffective problem solving and judgment; inappropriate or unconventional social behavior; and impaired executive and metacognitive functions: self-awareness of strengths and weaknesses, goal setting, planning, self-initiating, self-inhibiting, self-monitoring, self-evaluating [5]. Hagen [6] has stated that, a cognitive impairment can be manifested in linguistic impairments as well, so that a result of the breakdown of well-structured mental processes is also represented by: • • • • • •
decreased auditory and reading comprehension; expressive language which does not make sense to the listener; tangential language, completely irrelevant to the topic; inability to inhibit verbal expression; inappropriate word order and/or grammar; inability to recall specific words.
With this in mind, the speech-language pathologist approaches the patient assessment as a dynamic process of information gathering with regard to (1) the patient's ability to effectively use all forms of language in a variety of environments; and (2) determining which and to what extent cognitive processes are impaired.
46
J. lacarino / NeuroRehabilitation 8 (1997) 43-48
Although there is great value to the use of formal measures with traumatic brain injury patients, it can never be considered the last word for providing diagnostic information to the team. Ylvisaker and Szekeres [7] consider assessment as a form of hypothesis testing regarding the patient's strengths and weaknesses. These hypotheses are then accepted or rejected based upon record reviews, family interviews, formal tests, informal tasks, and, finally, diagnostic treatment. Intervention strategies vary greatly, depending on many factors, including overall cognitive abilities, specific cognitive impairments, and length of time post-injury. Certain strategies frequently used are: •
• • •
•
Environmental manipulation: changing the environment in some way to simplify tasks for the patient (e.g. placing a schedule in the same location so it can be easily located). Training task specific routines: teaching the procedures necessary to accomplish a particular task. Attention process training: systematically increasing the amount of time one is successfully able to attend and complete a task. Compensatory strategies: using additional methods of remembering, such as log books, chunking numbers, mnemonics, cognitive devices. Metacognitive strategies: training patients to question their behaviors toward successful completion of a task or activity [6-9].
'The loss of social grace is perhaps the most devastating thing that most clients face after head injury' [8]. The arena of 'social skills' presents a classic example of the interaction of language and cognition, with cognitive skills such as orientation, attention/concentration, memory, organization and problem solving/judgment serving as the basic underpinnings for the successful communication interaction [10]. Given the resulting high occurrence of deficits in social discourse, its' direct impact on all daily interpersonal activities, and its' direct effect on long term success, it is an area of major importance for the speech-language pathologist. Again,
intervention varies, but includes cogmtlve and meata-cognitive training of appropriate social skills. A final stage is transfer and maintenance of these behaviors to other environments where they can be practiced. In the long recovery process the role of social discourse increases dramatically in importance as the individual returns to the community. 4. Future practice guidelines At the current rate, by the year 2050, 100% of the gross national product, will be dedicated to healthcare [11]. Clearly, new and creative strategies must be implemented for provision of rehabilitation services. Two criteria must be met in this process, however: technical excellence in the form of innovative treatment for cognitive rehabilitation; and a cost effective environment. As we explore these challenges, it becomes evident that current practices may not meet those criteria as efficiently as possible. With this trend in effect, we as Ph.D. and Master's level speech-language pathologists will more frequently find ourselves in the role of consultant/supervisor, and less often as direct service provider, so the salary dollars can be stretched. In this section, we will explore these options for future opportunities. A strategy which has been employed in other disciplines and is re-emerging as a viable option in speech-language pathology, is the use of support personnel in a variety of capacities. The 1994 Task Force of Support Personnel [12] has endorsed this concept in a position statement, and presented a series of guidelines of responsibilities for the speech-language pathology assistant, as well as for the speech-language pathologists who will assume the supervisory role. Accordingly, the American Speech-Language- Hearing Association has passed this resolution at the 1996 session of the Legislative Council, making this an official position of ASHA. Although guidelines were originally established by ASHA in 1981, the current specifications are more stringent, in that the present criteria require an associate of arts degree or equivalent, clinical practicum hours, and successful completion of a national examination, all leading to a certification. Each state may establish a
J. Iacarino / NeuroRehabilitation 8 (1997) 43-48
license. As these are more demanding than the original prerequisites, the responsibilities are greater. Essentially, speech-language pathology assistants may conduct screenings, provide treatment assistance or direct treatment when following a prepared treatment plan, assist in assessment, assist with documentation, schedule, and participate in research projects, in-service training and public relations programs. Under this structure, the speech-language pathologist still retains the legal and ethical responsibilities for all assistants providing care under her supervision [13,14), Additionally, speech-language pathology aides are currently being utilized in various settings. As credentials have not yet been established nationwide, and there are currently no criteria for their training, they are usually trained on-site to work with a very specific population, and have an extremely restricted role in provision of services. However, to the extent that they may allow the speech-language pathologist increased direct treatment time by preparing materials or equipment, they are extremely helpful. A variation on this theme is the rehabilitation aide, who serves as an attendant for all disciplines (OT, PT, and Speech) where needed. The key factor is the individual with an understanding of rehabilitation concepts who becomes a motivated participant in the process of maximizing patient success. From the cognitive rehabilitation perspective, there will be a multi-level system of individuals created with varying degrees of expertise in speech-language pathology, essentially developing a team of providers. Although this difference in qualifications exists, in essence, training in rehabilitation concepts for everyone regardless of level of personnel maximizes the potential for that facility to provide successful outcomes. Another proposed alternative for provision of services utilizes the model of a single individual who is cross-trained to supply treatment in more than one discipline. This is the concept of multiskilling. This has been recognized by some as the optimal solution for maximizing the healthcare dollar [3]. In contrast to supplementing healthcare professionals with support personnel, the one choice in the concept of multi-skilling sug-
47
gests that professionals may expand their scopes of practice to increase the amount of services one is able to provide. These services may include basic patient care, clinical or administrative skills. Pietranton and Lynch [11] report that multiskilling, although not new, is having a resurgence in popularity because it is viewed by many as the best option for positioning healthcare for the future. For as many individuals who feel that this is the solution, an equal number fear this choice as the downfall of high quality services. Although it can be viewed by some as a particularly cost effective way to provide a multitude of services, multi-skilling may present a new. danger: the treating of patients by individuals who are, in essence, 'jacks-of-all-trades, masters of none', possibly compromising the quality of service. The evolution of this job title remains to be seen. To date, it has only been loosely defined, and may have the potential to offer many alternatives for health-related careers, from professionals to non-professionals. Undoubtedly, it is an unusual twist on current training practices for healthcare professionals, however, the ad hoc committee on multi-skilling of ASHA has pointed out that practitioners have already begun the move toward expanding practices, with speech-language pathologists treating swallowing disorders as an example [13]. In summary, the evolution of rehabilitation professionals has only begun. Driven by managed care and other alterations in reimbursement, the conclusion of this century should see a major reorganization in the provision of services. It is essential that throughout this restructuring, priorities remain clear, specifically the maximal outcomes for the consumers of our services. To this end, increased interaction and shared information among disciplines is paramount. How this is accomplished presents options for innovative progress in rehabilitation for the future. References [1]
Henri B. Graduate student preparation: tomorrow's challenge. ASHA 1994;36(1):43-46. [2] American Speech-Language-Hearing Association. Role of Speech-Language Pathologists in Habilitation and
48
[3]
[4]
[5]
[6]
[7]
J. lacarino / NeuroRehabilitation 8 (J997) 43-48
Rehabilitation of Cognitively Impaired Individuals, ASHA Desk Reference, Vol. 3, 1987. American Speech-Language-Hearing Association. Technical report of the ad hoc committee on multiskilling. ASHA 1996;38(Suppl. 16):53-61. American Speech-Language-Hearing Association. Guidelines for speech-language pathologisis serving persons with language, socio-communicative and/or cognitive-communicative impairments. ASHA 1991 ;33(Suppl. 5):21-28. American Speech-Language-Hearing Association. Role of Speech-Language Pathologists in Habilitation and Rehabilitation of Cognitively Impaired Individuals, ASHA Desk Reference, Vol. 3, 1987. Hagen C. Language disorders in head trauma. In: Costello J and Holland A, eds. Handbook of Speech and Language Disorders. San Diego, CA: College Hill Press 1996;1011-1012 Ylvisaker M, Szekeres S. Management of the patient with closed head injury. In: Chapey R, ed. Language Intervention Strategies in Adult Aphasia. Baltimore,
[8] [9]
[10]
[11] [12]
[13]
[t4]
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