Speech-Language Pathologists (SLPs) are the Most Qualified Providers for Dysphagia Services

ASHA maintains that speech-language pathologists (SLPs) are the most qualified providers of dysphagia services in all practice settings. Although SLPs work collaboratively with other disciplines (e.g., gastroenterology, occupational therapy, otolaryngology, nutrition and dietetics radiology) in highly skilled interprofessional teams, SLPs are uniquely trained in management of swallowing disorders.

Knowledge and Skills

The overall knowledge and skills obtained by SLPs in their professional training provides an exemplary and essential foundation for successful evaluation and treatment of dysphagia in children and adults resulting from any etiology. Entry-level professional standards for ASHA-certified SLPs as established by the Council for Clinical Certification in Audiology and Speech-Language Pathology (CFCC) indicate that all practicing SLPs (at a minimum) possess knowledge of “Swallowing/feeding, including (a) structure and function of orofacial myology and (b) oral, pharyngeal, laryngeal, pulmonary, esophageal, gastrointestinal, and related functions across the life span” (Standard IV-C) and “basic human communication and swallowing processes, including the appropriate biological, neurological, acoustic, psychological, developmental, and linguistic and cultural bases” (Standard IV-B). Additionally, SLPs also receive training in swallowing and swallowing disorders across the lifespan, including aging and its effects on swallowing function as well as the impact of trauma and disease on swallowing function.

Beyond the entry-level knowledge and skills, SLPs continue to acquire extensive continuing education in swallowing and swallowing disorders. In 2020 alone, 133 unique ASHA Approved Continuing Education Providers offered more than 5,700 courses in dysphagia that resulted in over 340,000 hours of continuing education taken by SLPs in a single calendar year.

Clinical specialty certification in swallowing and swallowing disorders is available for SLPs who meet the stringent requirements of the American Board of Swallowing and Swallowing Disorders for advanced competencies. A clinician who meets these requirements is designated as a Board Certified Specialist (BCS) in Swallowing and Swallowing Disorders and may use the initials “BCS-S” following their name.

Payer Guidance

In its discussion of services for dysphagia, the Centers for Medicare & Medicaid Services (CMS) states that “it is important that only qualified professionals with specific training and experience in this disorder provide evaluation and treatment” (Medicare Benefit Policy Manual [PDF], p. 211, section 230.3). In further discussion of dysphagia services within the practice of speech-language pathology, CMS notes that “Swallowing assessment and rehabilitation are highly specialized services. The professional rendering care must have education, experience and demonstrated competencies. Competencies include but are not limited to: identifying abnormal upper aerodigestive tract structure and function; conducting an oral, pharyngeal, laryngeal and respiratory function examination as it relates to the functional assessment of swallowing; recommending methods of oral intake and risk precautions; and developing a treatment plan employing appropriate compensations and therapy techniques” (Medicare Benefit Policy Manual [PDF], p. 212). SLPs are the only rehabilitation discipline who have this level of specialized training to provide dysphagia services. Furthermore, in light of the specific expertise outlined, CMS does not discuss provision of dysphagia-related services as being within the scope of any other discipline, including occupational therapy.

Experience

SLPs have extensive experience in providing dysphagia services. According to the ASHA 2021 Health Care Survey, almost 60% of SLPs in health care settings indicated that dysphagia was among the top five diagnoses on their caseloads. The trend report [PDF] of caseload characteristics indicates that SLPs engage in dysphagia-related service delivery to adults for over 40% of their caseload across health care settings.

Professional Leadership

In addition to the expertise of individual clinicians, SLPs have led the efforts to advance the knowledge and skills in dysphagia practice—far more than any other profession:

SLPs, working alone and in collaboration with clinicians and scientists in other professions, have conducted and published the majority of existing research on normal swallowing function and dysphagia treatment, including research on the following topics:
- neural substrates contributing to swallowing function
- temporal and kinematic measures of normal and abnormal swallowing
- relationships between pressure generation and structural function in oropharyngeal and cervical esophageal swallowing
- coordination between respiratory and swallow systems
- impact of bolus characteristics (taste, volume, viscosity, etc.) on normal and abnormal swallowing physiology
- contextualizing performance within a clinical trajectory and/or team plan of care
- effect of compensatory strategies (e.g., postures, maneuvers, bolus variables)
- effect of exercise (e.g., strengthening, skill-based)
- clinical trials with specific patient populations to assess effects of treatments on health outcomes
- measures for assessing treatment outcomes
SLPs developed and disseminated preferred practices for clinical and instrumental procedures for evaluating swallowing and feeding disorders.
SLPs have been active members of the Dysphagia Research Society (DRS), a multidisciplinary group interested in research on normal and abnormal swallowing, since its origin in 1992. SLPs currently compose a large percentage of DRS membership.
ASHA’s National Center for Evidence-Based Practice in Communication Disorders (NCEP) has the only systematically obtained national database of clinical outcomes for dysphagia services when such services are provided by appropriately trained ASHA-certified SLPs. This database is called the National Outcomes Measurement System (NOMS).

ASHA has a well-developed program of support for SLPs involved in dysphagia:

Policy documents (e.g., Preferred Practice Patterns) and practice recommendations for swallowing and feeding disorders, videofluoroscopic swallowing studies, endoscopic evaluation of swallowing, and swallowing disorders in schools.
A Special Interest Group (SIG) that focuses on swallowing and swallowing disorders (SIG 13).
Continuing education programs and materials such as self-study programs and conferences.
Requirements for ASHA’s Certificate of Clinical Competence in Speech-Language Pathology (CCC-SLP) include the attainment of knowledge and skills in swallowing and swallowing disorders.
Competency standards via the ASHA-developed Dysphagia Competency Verification Tool (DCVT).

ASHA maintains that “Educating other professionals about what audiologists and speech-language pathologists do can expand our service delivery and allow us to reach children and adults with communication disorders who might not otherwise be referred to us or who might be referred too late or later than the optimum. However, teaching other professionals to do what we do can be dangerous. All of the particular aspects of what we do that make our treatments and evaluations successful cannot be taught in any short-term continuing education environment to individuals who do not have the intensive graduate education required for audiologists and speech-language pathologists. How we successfully select and apply the assessment and treatment procedures we use depends upon our background knowledge of normal and abnormal function in each of the areas in which we work. Other professionals do not come to our continuing education programs with that kind of educational background. In addition, to teach another professional to do what we do opens up the possibility of an unnecessary and potentially unhealthy competition that could compromise outcomes for patients or even their well-being.

ASHA emphasizes to all internal and external stakeholders (including employers and policymakers) that SLPs are the most qualified providers of dysphagia services and that the foundation of their knowledge and skills in swallowing and feeding is not transferable to other professions. In addition, Multiskilled Personnel (a position statement published by ASHA) states that “cross-training of clinical skills is not appropriate at the professional level of practice" (para 1). The ASHA Code of Ethics (2016) has several provisions that address the delegation of responsibilities:

Principle I, Rule E: Individuals who hold the Certificate of Clinical Competence may delegate tasks related to the provision of clinical services to aides, assistants, technicians, support personnel, or any other persons only if those persons are adequately prepared and are appropriately supervised. The responsibility for the welfare of those being served remains with the certified individual.

Principle I, Rule F: Individuals who hold the Certificate of Clinical Competence shall not delegate tasks that require the unique skills, knowledge, judgment, or credentials that are within the scope of their profession to aides, assistants, technicians, support personnel, or any nonprofessionals over whom they have supervisory responsibility.

Principle I, Rule G: Individuals who hold the Certificate of Clinical Competence may delegate to students tasks related to the provision of clinical services that require the unique skills, knowledge, and judgment that are within the scope of practice of their profession only if those students are adequately prepared and are appropriately supervised. The responsibility for the welfare of those being served remains with the certified individual.

Each profession is different in its academic and clinical preparation; thus, a professional cannot make assumptions about the knowledge base or experience of someone from another discipline. SLPs could be held responsible for a professional in another discipline working under the auspices of SLP training. Furthermore, many such requests from administrators may be based on the expectation that competency in dysphagia management can be acquired quickly by attending a course or by observing another professional for a short period of time. ASHA strongly recommends that in instances of personnel shortages, administrators investigate alternative strategies for staffing and service provision by competent SLPs.