MDS and SLP Collaboration

Speech-Language Pathologists (SLPs) maintain an important role in identifying patients who could benefit from skilled intervention. The Centers for Medicare and Medicaid Services recognizes the impact of swallowing deficits and cognitive disorders on residents in SNFs. Under PDPM it is essential that speech-language pathology services are reflected on the Minimum Data Set (MDS).

Input and documentation from SLPs are imperative to supporting several sections of the MDS:

Section C-Cognitive Patterns: including the Brief Interview of Mental Status (BIMS), repetition of three words, temporal orientation, recall, staff interview, short-term memory, long-term memory, recall ability, and cognitive skills for daily decision-making and safety.
SLPs can assist by: Utilization of standardized assessments and implementation of functional cognitive goals.

Section K-Swallowing and Nutritional Status: including loss of liquids/solids from mouth when eating or drinking, holding food in mouth/cheeks or residual food in mouth after meals, coughing or choking during meals or when swallowing medications, complaints of difficulty or pain with swallowing, and a mechanically altered diet while a resident.
SLPs can assist by: Documenting a comprehensive oral motor examination, including dental status.

Sections I & O-Clinical Category: PDPM Clinical Categories that may be associated with speech therapy services include aphasia, CVA, TIA, stroke, hemiplegia or hemiparesis, traumatic brain injury, laryngeal cancer, apraxia, dysphagia, ALS, oral cancers, speech and language deficits, tracheostomy care while a resident, and ventilator or respirator while a resident.
SLPs can assist by: Ensuring accurate and specific coding and supplying supportive documentation.

Effective collaboration between nursing, therapy, and administration upon the patient’s initial evaluation ensures the patient is assigned to the correct clinical and payment categories. Synchrony Rehab SLPs and Program Directors can contribute to accurate representation on the MDS. The SLP’s input and justification through comprehensive assessment and supportive documentation regarding these MDS sections ensures accuracy of the data, helps identify patients who need speech-language pathology services, highlights the benefit of speech-language pathology intervention, and facilitates communication among the interdisciplinary team which leads to better patient care overall. Working together promotes ongoing patient access to medically necessary intervention and ensures that speech-language pathology services are valued for their significant contributions to patient care.