POSITION STATEMENT: SPEECH LANGUAGE PATHOLOGY ASSISTANT LICENSURE

The issue of licensing Speech Language Pathology Assistants (SLPAs) in Ohio has been a topic of discussion over the past decade.  In 1998, after two years of study, the Ohio Speech-Language-Hearing Association (OSLHA) issued a position statement indicating that the organization did not support the licensing and use of SLPAs in any setting.  Once again in 2005, with continued study and monitoring of the issue, OSLHA along with the Ohio School Speech Pathology Educational Audiology Coalition (OSSPEAC), the Ohio Academy of Audiology (OAA) and the Ohio Council of Speech and Hearing Administrators (OCSHA) concur that we do not support the licensing and use of SLPAs to treat children and/or adults with communication and/or swallowing disorders in any setting including schools, hospitals, clinics, or nursing homes.  The leadership of the aforementioned organizations representing approximately 3,500 professionals supports this position. 

SUPPORTING RATIONALE

 The supporting rationale is based on the need to provide quality service to the consumer and to insure that the consumer is not confused or misled by the skills and abilities of the Speech Language Pathologist versus those of the Speech Language Pathology Aide or the Speech Language Pathology Assistant (SLPA).   

Definition of Roles and Responsibilities of the Speech-Language Pathologist, Speech-Language Pathology Aide and Speech-Language Pathology Assistant 

At this time there are two licenses granted in the area of speech-language pathology by the Ohio Board of Speech Pathology and Audiology:  Speech-Language Pathologist and Speech-Language Pathology Aide. 

The scope of practice of the Speech-Language Pathologist  (Master’s Degree required plus 375 clock hours of clinical practicum) as outlined in the Ohio licensure laws includes serving culturally, linguistically, and diverse populations through: performing diagnostics and evaluations including interpretation of results and feeding/swallowing evaluations, developing, modifying and delivering individualized treatment plans, selecting and discharging clients from service, participating in parent and case conferences including interdisciplinary team meetings, signing formal documentation, counseling clients and their families and consulting with other professionals.

 The scope of practice of the Speech Language Pathology Aide (High School degree or equivalent) as outlined in the Ohio licensure laws includes: developing materials, maintaining assistive and prosthetic devices, completing clerical duties, scheduling activities, preparing charts and data displays, and assisting with speech-language screenings.  The scope of practice of a Speech Language Pathology Assistant (SLPA) (Generally Associate Degree and 100 hours of clinical practicum) as suggested in the literature includes the same duties of the Speech-Language Pathology Aide and the additional ability to follow documented treatment plans or protocols developed by a supervising Licensed Speech-Language Pathologist. A more detailed comparison of the roles/responsibilities of the SLPA can be found in Chart 1 (see attached).  In 1999 the American Speech-Language-Hearing Association surveyed its members who were supervising SLPAs in their work settings to assess the value of the SLPA.  Only 11.1% of the Speech-Language Pathologists positively described their experiences with Speech-Language Pathology Assistants as “usually helpful, but there are limitations to their effective use.”  The majority of the survey responses were negative.

 Quality of Services to the Consumer

 The requirement for a Licensed Speech-Language Pathologist to provide service is the standard for Medicare, managed care providers, insurance companies, and the Ohio Department of Education.  It is important to note that in the case of adults with Medicare coverage, effective June 6, 2005 the services of SLPAs are no longer recognized for coverage (Medicare Benefit Policy manual, Section 15/230.3.C).

 Ohio’s licensure law requires a Master’s Degree and a minimum of 375 hours of supervised clinical practicum.  This standard for Licensed Speech-Language Pathologists was implemented in the mid-seventies to ensure quality service and is based on the standards of the American Speech-Language-Hearing Association who administers the Certificate of Clinical Competence (CCC) to qualified Speech-Language Pathologists.  As a comparison, most current SLPA training models require only 2 years of education beyond high school and100 hours of supervised clinical practicum.

 Using SLPAs for treatment would compromise the quality of services to the children in our schools and adults in hospitals, out patient clinics, and long term care facilities.  Even with the addition of SLPAs, a licensed Speech-Language Pathologist would still be required to provide diagnostics and treatment plans as well as the ongoing supervision of the SLPA.  This situation would have the most qualified therapy provider completing supervisory work rather than directly working with the individual with the communication and/or swallowing disorder and the family.  The length of time for treatment and recovery of many communicative disorders might be extended or prolonged with the use of SLPAs.  Extended therapy along with ceiling caps for Medicare Part B and prescribed numbers of visits (which are currently based on Speech-Language Pathologists providing the direct therapy)by managed care providers or insurance companies, would shift the financial burden to the consumer and in many cases treatment would be terminated due to the inability of the consumer to pay for the additional sessions provided by the SLPA.

 In states where SLPAs are being utilized difficulties with maintaining required levels of supervision are reported.  For example, a study of SLPAs in Illinois by Jay Lubinsky, Ph.D. (online April 13, 2005 http://www.asha.org/NR/rdonlyres/8557563C-64E4-4AD5-9859-54CE514B2F7D/0/221Handout.ppt#2) revealed that 68% of SLPAs were not supervised as required by law.  Additionally, SLPA’s planned treatment without supervision or Speech-Language Pathologist input in 65% of the settings, assessed children independently in almost half of the settings and attended meetings without the SLP present in over one quarter of the settings, all in violation of the licensure law.

 Confusion of the Consumer

Given a 3-tiered model of service delivery providers, there is the danger that the public, parents, professionals and employers would be confused, and therefore recognize and treat the SLPA as a Licensed Speech-Language Pathologist. The consumer may assume that they are receiving the same quality services from the SLPA as compared to what they could receive from the Licensed Speech-Language Pathologist.  As explained above SLPAs may not perform diagnostic tests or conduct evaluations, develop and write treatment plans, sign formal agreements, or select or discharge clients from services.  Such confusion may lead to fraudulent claims and malpractice suits.

 Legal Liability

 The liability implications of SLPAs providing treatment are of major concern as clients served by the SLPA are the responsibility of the supervising Speech-Language Pathologist, who is legally responsible for all services.  At the state level additional Licensure Board responsibilities to oversee the licensing and supervision of SLPAs would add unnecessary bureaucracy and additional expense to an already austere budget.  Professional liability at the local level would need to be reviewed to assess the position of any agency employing SLPAs in cases of malpractice. Transferring duties and directly supervising a SLPA is a professional decision that can only be made by a Licensed Speech-Language Pathologist, not by administrators (e.g. rehabilitation manager), school principals, or supervisors.

 SLPA Usage Not Effective in Alleviating Shortage

 Utilizing a SLPA changes the Speech-Language Pathologist’s role to that of supervisor and may not be as efficient as one would think.  The professional retains the legal and ethical responsibilities for all service provided or omitted.  The American Speech-Language-Hearing Association (ASHA) guidelines maintained that a SLPA be directly supervised 30% of the time for the first 90 days and 20% of the time thereafter.  ASHA guidelines further recommend that no more that 3 SLPAs should be supervised by one Licensed Speech-Language Pathologist.  For example, a Speech-Language Pathologist working full time, 5 days a week, would be required to spend, at a minimum, 1 day per week (or 20% of their time) supervising the assistant.

 In reviewing the published data on the use of SLPAs, it was found that our neighboring state West Virginia created a provision that allowed the hiring of SLPAs as independent providers in shortage areas.  Assistants did not end the shortage of Speech-Language Pathologists in the West Virginia schools, and since then the state policy has been rescinded (November 2003, ASHA Leader). North Carolina utilizes SLPAs but because of the newness of the profession they do not yet have data on the impact of the supply and distribution of speech language pathologists within their state.  Drawing from an earlier study of physical therapy assistants they found several trends that may well be replicated in the speech language pathology workforce in the coming years.  Selective employment of physical therapy assistants instead of physical therapists seemed to be occurring, especially in rural underserved communities.  Such a trend may be expected to occur in settings such as schools and urban/rural underserved areas for speech language pathology. (North Carolina Health Professions Data System. Communicating the Trends: Speech-Language Pathology Workforce Assessment Project,  June, 2001.  Online March 5, 2005 at www.shepscenter.unc.edu/hp).

 Reimbursement

Under the existing Medicare part B regulations, managed care provider procedures, and insurance company protocols, the only person that may sign and document any formal treatment plans is a Licensed Speech-Language Pathologist (North Carolina Health Professions Data System. Communicating the Trends: Speech-Language Pathology Workforce Assessment Project,  June, 2001.  Online March 5, 2005 at www.shepscenter.unc.edu/hp).   SLPAs and services provided by a SLPA are not recognized or defined in Medicare law or regulations.  A Licensed Speech-Language Pathologist is the only person who may sign for Medicaid reimbursement.  As reported in the study, difficulties have been and would continue to be encountered in obtaining reimbursement for services rendered by SLPAs.  Finally, funding tied to the Individuals with Disabilities Education Improvement Act of 2004 (IDEIA) requires a properly credentialed Speech-Language Pathologist to assess a child who exhibits a communication and/or swallowing disorder.

 Scarcity of SLPA Training Programs

 There are currently fewer that 30 SLPA training programs throughout the United States (less than 1 per state), and there are no such training programs in the state of Ohio.  Given the current budget climate and funding being allocated to higher education, the development of such programs is prohibitive.  Nationally, the trend is moving away from SLPAs.  In fact, training programs in Indiana and Illinois are in the process of closing.  In 1998, the American Speech-Language Hearing Association (ASHA) developed a procedure to formally recognize SLPA training programs and to register SLPA practitioners.  Both programs were eliminated in 2003 due to lack of national interest in establishing programs, insufficient numbers of SLPAs and continuing concern regarding the use of SLPAs.

Unwarranted Comparisons Between Occupational/Physical Therapy and Speech-Language Pathology

 Many individuals point to the success of the assistant model within the professions of occupational and physical therapy (OT/PT) as a model for speech-language pathology.  These comparisons are unwarranted in many respects.  Occupational and Physical Therapists are currently licensed through completion of a Bachelor’s Degree.  In addition, many responsibilities of the Occupational and Physical Therapist include routine or repetitive tasks such as packing, massaging, and range of motion exercises which are conducive to the use of occupational or physical therapy assistants. 

 Few responsibilities of the Speech Language Pathologist are routine tasks.  Communication and/or swallowing disorders are very complex.  The Speech Language Pathologist provides intervention addressing cognitive and memory disabilities, and facilitates complex linguistic and articulatory changes.  Intervention requires ongoing, immediate modification of strategies.

PROPOSED ACTION PLAN

 OSLHA and OSSPEAC, as professional associations, are available to work collaboratively with the State Legislature; Legislative Office of Education Oversight; Ohio Department of Education, Office for Exceptional Children; and The Ohio Board of Speech-Language Pathology and Audiology concerning the shortage of Speech-Language Pathologists in Ohio.  We are committed to finding a long term solution to the problem.

 The SLPA laws in other states have not worked to the benefit of the consumers nor the profession (www.asha.org) Instead of supporting the licensing of SLPAs, efforts to fulfill the increasing need for Speech-Language Pathologists in the state of Ohio have been undertaken within the profession.  These  efforts include:

 Existing Actions 

Ohio Master’s Network Initiatives in Education, (OMNIE) was originally created in 1997.  OMNIE provided an innovative, efficient distance learning program to upgrade the education of school based practicing bachelor’s level Speech Language Pathologists to a Master’s Degree.  This joint effort by the state universities in Ohio, the State Speech Language Supervisory and Audiology Network and the Ohio Department of Education resulted in 58 graduates.  Following that success, OMNIE expanded to include the following: 

·        A recruitment program that has been distributed to 873 public, private and parochial high schools and approximately 100 institutes of higher learning in Ohio.  Members of the profession are working with teachers, high school counselors, and career counselors to encourage their students to enter the profession.

·        On-line undergraduate courses to prepare college students and post-baccalaureate students to enter Ohio’s graduate school programs in speech-language pathology.  This academic year there have been 72 student registrations.

·        Tuition reimbursement for 15-17 Ohio Board of Speech Pathology & Audiology licensed Speech Language Pathologists or Audiologists from the private sector to complete the additional requirements to obtain ODE licensure. 

·        Incentive and opportunity for 43 Speech Language Pathologists/Audiologists to obtain ODE licensure in speech language pathology or educational audiology through tuition reimbursement

·        Thirteen sign-on bonuses awarded to graduating speech language pathologists who accepted a position in Ohio’s schools in 2004.  Eighteen incentives are available for this year’s graduates.

·        Sign-on bonuses of  $2000.00 dollars were offered to five school districts that have had an open speech language pathology position for over twelve months.  For the 2005-2006 school year, OMNIE will provide $4000.00 dollar sign-on bonuses in each of twenty districts.  Newly employed Speech Language Pathologists will receive $2000.00 dollars during the 2005-06 school year and an additional $2000.00 dollars during the second year of employment in the same district (2006-2007).

·        A graduate level web-based course entitled “Administration of Speech Language Programs in Schools” is available for Ohio Board of Speech Language Pathology & Audiology licensed Speech Language Pathologists to assist in obtaining ODE licensure. 

Proposed Actions 

·        Recruit and utilize the Speech Language Pathology Aide position in all settings.  Currently the Aide License is underutilized.  There were 13 Aide licenses issued in 2004 across the state of Ohio.

·        The Legislative Office of Education Oversight (LOEO) study published in 1999 made several recommendations to improve the working conditions in the schools.  They identified unacceptable working conditions including:

o       A caseload in law of 80 students

o       Inordinate amounts of paperwork with little to no clerical assistance

o       Limited contact with teachers, and

o       General lack of support from administrators

In addition the LOEO reported that the salaries of those Licensed Speech Language Pathologists working in the schools were not commensurate with the salaries of Licensed Speech language Pathologists working in other settings.  These unacceptable working conditions persist and it is proposed that they be remedied.

·        Consider offering compensation for SLPs with their National Certification, the Certificate of Clinical Competence (CCC) from the American Speech Language Hearing Association.  This action would be similar to the compensation awarded to teachers who earn their National Board Certification.

·        Pursue paid tuition or stipends for school based practicum experience if the graduate student commits to work in “hard to place” areas upon graduation.  Additionally, provide host families and mentorships during that semester.

·        Consider state-funded financial incentives such as forgiving student loans for taking employment in underserved health professional shortage areas.

·        Study the feasibility of a distance Master’s program.  The number of speech language pathologists graduating with Master’s degrees does not keep up with the projected need (270) of new Speech Language Pathologists across all practice sites in Ohio (projection by US Department of Labor and Statistics).

·        Develop incentives such as sign on bonuses or loan forgiveness for graduates to accept positions in Ohio