Sunday, February 2, 2020

Speech Therapy in the School vs. Pediatric Outpatient Setting

Recently, I mentioned that I had made the switch from schools to a pediatric outpatient setting. I have found that there are LOTS of differences between the two, but I have loved my new position. I have been at my "new" job for about 18 months now, so I feel like I have a good understanding of all the responsibilities and expectations at this point. I feel like I made the best decision for me and my family. But I also know that everyone's situation is different. I thought I would write about some of the differences I've encountered so that others looking to make this switch or trying to decide between the two for a first job could have some more information.

1.) 1:1 Ratio - In schools, I did push in therapy in the preschool classrooms. Pull out therapy was typically in groups of 2-4 kids. My school was short staffed, so I was way over the state limit on students. At one point, I had 96 kids on my caseload. I usually had around 75-80 kids to see in a week. At the hospital setting, I only do pediatric outpatient with one patient at a time. I can give my undivided attention to that one patient. I only see about 28 patients per week (I work 32 hours per week).

2.) Parent Involvement - In schools, I may never meet some of my students' parents. If they didn't come to the annual IEP meeting or parent-teacher conferences, I didn't see them. I tried to make an effort to communicate with them via parent handouts, but who knows if they actually saw them. Because a caregiver has to bring the patient to the hospital, I get a chance to touch base with them at each session. Some parents come back to the therapy room and participate in the activities. If I send home a parent handout or homework, I know the parent got it because I hand it right to them after the session.

3.) Insurance - In schools, if a kid qualified for services, they got the service. That's not so much the case in hospitals. Someone has to pay for these services. If their insurance won't cover it, they don't get it. Insurances will often have a set amount of visits that they will pay for. If your patient hasn't met their goals yet, you can request more. But no promises that you'll get them. That can be frustrating when you know a kid needs a little more help. You also have to meet deadlines and what not with insurance, much like IEPs.

4.) Patient types - In schools, you typically work with a specific age range. For the first few years that I was in schools, I worked with preschool - 3rd grade. When we became short staffed, I had preschool  - 8th grade. My pediatric setting sees patients aged 0-21. I currently have no patients in middle school or older. However, I know that this is a possibility in the future. Also, because we see patients under 3, the hospital required that I get my Early Intervention certification upon hire (paid for by them). This often allows us to bypass insurance for those little bitties to ensure they get the services that they need. I had not worked with patients that little before, so it is definitely a learning experience for me.

5.) Work at home - I have literally NEVER brought work home from the hospital. I have stayed late at work to finish things before, but I am paid hourly so no big deal. And it was never REQUIRED of me to do that. In schools, I was contracted to work from 8-3:45. I often got to work at 7:30 and worked until 4:15-4:30. And still brought stuff home. I was salaried, so I didn't get paid for all that extra time. The full time SLPs that I work with are salaried. If they stay late, they aren't necessarily getting paid for that. But our hospital recognizes that and will make concessions later. For example, if their last patient of the day cancels, they can leave early without taking vacation time.

6.) Productivity - The hospital does have a "goal" of 75% productivity. So, if I am at work for 8 hours, my goal is to be doing something billable for at least 6 of those hours. It can be hard in outpatient. When the weather is crummy, you often have a lot of cancels. However, the productivity is averaged across the month. So you'll have other, busier days that will balance it out. It is important to note that I feel like my hospital has a very reasonable productivity goal. When I talk with therapists doing inpatient at other hospitals or SNFs, I find that they are often at the 85-90% range. Furthermore, our hospital treats this as a goal. If you meet it, great! That will be reflected in your annual review and performance raise. If not, that's okay - unless of course you're at some ridiculously low amount. I have never had anyone question my productivity, even when it was lower.

7.) Paperwork - There is so much less paperwork at the hospital - which really shocks me! In schools, I did a daily note for each student. We had an annual IEP. Every three years, we went through the evaluation process again. Then I had a separate area where I went in to bill Medicaid for students. There was progress reporting to be done each quarter. At the hospital, I still write a daily note. However, the insurance billing is built into that program. So it takes me a few seconds to bill. We evaluate annually, but you don't have to have so many meetings and do so much paperwork just to get permission to evaluate. I do progress reports when their insurance asks for it. One insurance company that we work with wants a progress report every 12 visits - around every 3 months. That is the most frequently that I have to do them. Plus, not every patient's report will be due at the same time.

8.) Possibility of inpatient - When I took this job, I knew that there would be a possibility of covering inpatient in an emergency. We have an inpatient SLP and a PRN SLP that does inpatient as well. We are never "on call." However, if the inpatient SLP has an emergency and the PRN SLP can't cover, I know that I might have to cover. This has happened once since I started and that was only because our PRN SLP was on maternity leave. I don't love doing this, but I am comfortable with it. Not to mention, it is highly appreciated by my boss, the doctors, and the inpatient staff.

9.) Frequency of therapy - In schools, I often saw kids for 20-30 minutes, 2 - 3 times per week. In hospitals, I see them for 45 minutes to an hour, 1 time per week. Most insurances will only give enough visits for 1x per week. I can see them more times per week if their insurance will allow me. There is no hospital rule against that. It just usually comes down to insurance and parent availability.

10.) Scheduling - Scheduling in both places can be a nightmare. Schools are hard because there are so many kids and so many restrictions about when you can take them. Then a new kid moves in, another kid moves out, you pick up 5 more kids, and discharge one kid. It is always changing. Hospitals present a different set of challenges. When you're working with school aged kiddos, it's hard to find a time that they don't miss school. Many of mine are under 5, so that makes it easier. But you are still counting on parents to bring them in for therapy. Parents may not be able to get the time off work or have reliable transportation.

11.) Caseloads - My state has a cap of 60 students per SLP. However, if a student needs it, you are often required to provide the service whether or not you are over your cap. Since you are federally mandated to provide those services, that often outweighs that state cap. We were short staffed, so I often had 75-80 kids on my caseload. The attitude is very much that if a kid needs it, you figure out how to get them the service. Even if that means sacrificing your prep or lunch or whatever. In the hospital setting, I pick up new kids until my schedule is full. At that point, the patient goes on a wait list. When we have a new opening, we call the first person on the wait list. There is no scrambling to squeeze them in somewhere.

12.) Teamwork - I am lucky that the hospital I work at has a whole pediatric outpatient department. I work with 2 other SLPs, 3 OTs, and 2 PTs. Our desks are centrally located, giving us a chance to catch up and share info throughout the day regarding patients that we share. However, I still feel like I miss a lot by not being able to regularly talk with my patients' teachers. We can get releases to talk with them, which we often do. However, it's a lot different than being able to quickly check in throughout the day. Some of patients do not receive any other services, so I really don't get a chance to collaborate as much with those kiddos. Our state's Early Intervention program allows for collaboration between professionals seeing that patient without releases. They also allow you to bill up to one hour per month for these conversations.

13.) Vacation time - When I made the switch, I worked in my contract to have every Friday off. I work 9-5 Monday through Thursday. This comes out to 208 days a year if I never take any vacation or holidays. In the schools, my contract was for 185 days. So I work about 23 more days a year. I also get vacation time, even though I am considered "part time." My vacation time is based on the number of hours I work. At the end of each pay period, hours are "deposited" into my vacation bank based on the hours I worked during that pay period. Right now, I earn about 4 hours per 60 hours worked. That will go up the longer I work there. Our outpatient therapy setting has a pretty relaxed policy about time off. I have never had an issue with requesting a day off. In schools, I got two personal days and 10 sick days per year. More time was able to be rolled over in the school. When I left I had about 50 sick days, but still only 2 personal days. As I am getting ready to face maternity leave, I am missing those 50 sick days! So hospital = less time total, but the time can be used for anything.

14.) Pay - I was working in schools in a state that had very poor education funding. For those extra 23 days a year I am working, I am earning about $35,000 more per year. Worth it. Right now, I am getting raises 2x per year. I will get a "years of experience" raise for 3 more years at the anniversary of my hire, assuming that I am in good standing. I have also gotten a cost of living + "success sharing" raise each October of 3%. This number can change from year to year. We also typically get a "success sharing" bonus in October if we meet so many of the hospital's goals. The amount changes from year to year, but this year it was $500. At the school, I received a 3% raise each year. I could also increase my pay rate by moving across the pay scale as I took more classes.

15.) Benefits - My health insurance is way better and way more affordable than what was offered at the school. The difference saved my husband and I about $350 per month in insurance premiums. We do not have co-pays if we use a primary care doctor within our health system. I feel like we spend less on health related expenses. We'll see how this year goes with having a baby! We also get short term disability insurance and life insurance paid for by the hospital. The hospital currently gives me 3% of my salary into retirement whether I put anything in or not. This amount will go up by 1% every 5 years that I work there until it hits 7%. They will also match your contribution for the first 3%. So right now, if I put 3% into retirement, they will put 6% in (3% match + 3% years of service contribution). My state required a 9.4% contribution into their pension system. I was required to put the full 9.4% in.

Overall, the benefits have outweighed the risks for me. However, it is important to note that when I made this switch, I didn't have any kids. I know that being on the same schedule as your children is invaluable to some. I also want to reiterate that I was coming from a school that was incredibly short staffed. A lot of extra responsibilities were being dumped on me with little to no support to handle them. It wasn't necessarily the school's fault. There is a shortage of SLPs almost everywhere. Plus, I worked in a high poverty school that people weren't exactly banging down the door to come to (but I LOVED it dearly). And our administration was locked into a union contract that was atrocious for SLPs. Since then, they have re-worked that union contact successfully. This has allowed them to fill some of those vacant positions.

If you are thinking about switching settings or trying to choose between the two, I hope this helps you! Make sure you ask lots of questions. Ask to talk to other SLPs that work there. Ask to observe the working environment. A place that has nothing to hide will let you do that. My direct supervisor was the one interviewing me, so I got a chance to get a feel for him, too. If it's not your direct supervisor doing the interviewing, ask to meet them. A great job can be ruined by a crummy supervisor. I also got to meet the person who would be mentoring me those first few weeks and ask her questions. Like I said, a place that has nothing to hide will have no problem with you doing that!

Good luck! :)

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