Three Major Challenges of Long-Term Acute Care Settings

Long-term acute care (LTAC) hospitals are facilities that specialize in the treatment of patients with serious medical conditions that require acute care on an ongoing basis. These patients are typically discharged from intensive care units, but continue to need more care than they would receive in a rehabilitation center, skilled nursing facility, or at home.

Who Are the Patients in LTACHs?

LTACHs are unique in their ability to care for chronically critically ill patients who require specialized and aggressive goal-directed care over an extended recovery period. Typical patients have multiple co-morbidities, multi-organ system failures, and significant loss of independence, following a traditional hospital stay.

The types of patients typically seen in LTAC hospitals include those requiring:

  • Prolonged mechanical ventilation for respiratory failure
  • Intensive respiratory care post tracheotomies
  • Ongoing dialysis for chronic renal failure
  • Management of multiple medical conditions
  • Pre- and post-organ transplant care
  • Post-surgical acute care
  • Multiple IV medications
  • Infection management
  • Complex wound care etc.

The typical LTAC patient is someone with three to six concurrent active diagnoses or someone who suffered an acute episode on top of chronic illnesses. The average length of stay in an LTAC hospital is 25 to 30 days.

What is the Role of the Speech-Language Pathologist (SLP) in LTACHs?

SLPs in LTACHs carry out all the traditional responsibilities of clinicians in typical adult medical settings. However, what makes the role of the LTAC SLP unique is the variable range of services provided to a complex patient population.

Since many patients have trachs or are ventilator-dependent, LTAC SLPs evaluate and treat swallowing impairments in these individuals in addition to checking tolerance for voice prostheses and speaking valves. They work closely with the Respiratory Therapists (RTs) and physicians (Pulmonologists, ENTs, etc.) towards vent weaning and trach decannulation.

LTAC SLPs also work closely with the patient, family, and staff on ways to optimize the patient’s communication, either using alternative and augmentative communication or language therapy. They play an important role in evaluating and treating cognitive deficits associated with acute conditions such as stroke and brain injuries, commonly seen in LTAC setting.

An important thing to remember is that most patients in the LTAC are critically ill with a low tolerance for rehabilitation. The goal of the rehab team in the LTAC setting is to work with the interdisciplinary medical team to improve the patient’s medical status, provide therapy to get them ready for intensive rehab, and facilitate recovery.

How to Overcome Challenges in the LTAC Hospital Setting

1. Managing a Complex Caseload

Patients in LTACHs have critical illnesses, complex medical diagnoses, multiple co-morbidities and can be a difficult population to manage. Further, being surrounded daily by all kinds of tubes, lines, trachs, vents, secretions, wounds, and illnesses can be unnerving. Such a complex caseload can be challenging for the LTAC SLP.

Confront this challenge by reminding yourself of your role as an SLP in the LTAC setting. You are there to evaluate the patient’s speech, language, cognitive, and swallowing skills.

Confront the challenges of a complex caseload by learning beyond your scope of practice. Be confident in your assessments; start thinking critically and learn to connect the dots between diagnoses, symptoms, impairments, pathophysiologies, and therapy. Be aware of the influence of various medical conditions, lab values, and medications on communication, cognition, and swallow function. Identify what needs to be treated immediately and prioritize goals for each patient on an individual basis.

I learnt quickly in my first few months as an LTAC SLP that a textbook approach to patient care is best reserved for classrooms. Once you start doing these things, working with the unique and varied LTAC caseload can help you grow tremendously as a medical SLP. What once posed a challenge will soon become invaluable experience.

2. Providing Competent Care

As medical SLPs, we are also forced to do a lot of training and learning on the job. One of the biggest challenges I faced as a new SLP in the LTAC setting was providing ‘competent care.’ I wanted to ensure I was providing care that was evidence-based and the best solution to each of my patient’s problems. That is where I was wrong.

To confront this challenge, I had to recognize and accept the things I did not know. That doesn’t excuse an SLP from not knowing the basics of dysphagia, instrumental evaluations, language, or cognitive rehab. What this means is that it is okay for you to acknowledge your areas of weakness, step out of your comfort zone, and continue to strive for competence. This can be done by taking online courses, attending continuing education workshops and meetings, and by keeping up with research articles and blogs.

The best way to become competent in the LTAC setting is to share and learn from other disciplines. The RTs, RNs, RDs, and physicians are all willing to educate and help you become competent in their areas of expertise. In exchange, they will look to the SLP each time they have a question about swallowing, communication, or cognition.

A successful clinician must also be skilled in critical thinking, problem-solving, and analyzing their thought process continually. That, in my eyes, truly defines ‘competent care.’

3. Making Difficult Decisions

In the LTAC hospital assessments, treatments, and clinical decisions are not always straightforward. You may find yourself faced with difficult questions when a patient or a family member refuses diet recommendations or you are asked to make a patient comfortable at the end of life. Can a patient eat? Should the NG tube be removed? What is the safest diet? Can a patient speak? Does the trach tube need to be downsized? What is the best method of communication? Can this patient understand what is being said? As an LTAC SLP, the answers to these challenges can take many forms.

The LTAC teaches you the importance of person-centered care. From elderly persons suffering from pre-existing conditions that complicate their course of treatment to technology-dependent individuals requiring ongoing intensive care, the key to confronting this challenge is to treat every patient with dignity, empathy, and compassion. You should learn to make decisions and recommendations after discussing the best plan of care with the entire medical team, most importantly the patient themselves.

Is the LTAC Setting Right for You?

With the average 25-day length of stay for patients, the LTACH setting strikes the perfect balance between diagnostic and therapeutic skills. Working as an SLP in the LTAC setting equipped me with the skills needed to overcome the above challenges. I also found it immensely gratifying and fulfilling.

There are days when you have to tell someone they may never eat anything by mouth again. You may have to counsel someone who may spend the rest of their life on mechanical ventilation. Someone may need you to discuss palliative care options with them. Those are the real challenges! Those are the days you fight it out. Overcoming these challenges goes a long way in making you a better clinician and person. I say this from personal experience.

The workplace for the medical speech-language pathologist is undergoing rapid changes, compelling us to be flexible and expedient in learning new techniques and procedures under high productivity demands. There is a new appreciation for multi-skilled, multifunctional, and cross-trained professionals. SLPs who can be independent learners, face conflicting situations, and overcome challenges will be better prepared to succeed in this ever-changing workplace. I owe the LTAC setting for preparing me in the best way possible.

It was confronting the challenge and stepping out of my comfort zone that allowed me to see what I can really do. I hope this post motivates you to do the same!