a caregiver and women in an SNF

Pros and Cons of Being an SLP in an SNF

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So, you are thinking about being an SLP in an SNF. Now, you are wondering what are the pros and cons.

Hi, I’m Julia, and I have been a traveling SLP for over 10 years. During that time, I’ve taken short-term contracts in all medical settings. I’ve worked in acute, inpatient rehab, SNF, LTC, and home health. I am here to hash out the pros versus cons of the SNF setting.

Side note: if you are thinking about being an SLP, definitely read this on the pros and cons of being an SLP.

First up, not all SNFs are created equal

SNFs can get a bad rap from clinicians. There are a lot of bad SNFs out there. The bad ones may only see you as a therapy factory. These may put your personal and psycho-social needs aside to drive you to work.

Okay, that may have sounded a little harsh, but yet it’s true. 

On the flip side, there are some amazing SNFs out there.

SNFs can be an opportunity to connect with your patients and provide therapy in ways that you cannot do in other settings.

Before a career move into the SNFs, I highly recommend looking at the SNF itself and seeing if it’s a place you want to work.

While you’re reading through this list, please remember that these are generalized pros and cons of being an SLP in an SNF setting. It is not a one-size-fits-all list. 

Pros of Working in an SNF

Flexibility

Clinicians gravitate towards SNFs for flexibility. In the majority of SNFs, as long as you come to work and see your patients, it doesn’t matter at what time you are there and when you leave. 

7-3:30, sure! 

10-6, okay!

Work PRN for a couple of hours a day, we’ll take it!

SNFs are a great setting to work in if you have a family or an ever-changing schedule. In any given geographic area, you might be able to find an SNF that would hire you full-time, part-time, or PRN. 

Thus, you can work a schedule in an SNF that fits your lifestyle and needs. 

Entry Into Medical SLP

The majority of medical SLP clinicians I know, including myself, have started their medical careers by working in the SNFs. Compared to other settings, such as acute care and home health, it is far easier to get a job as a novice clinician in an SNF. 

However, this can also have its downsides as many SNFs will hire you, but may not provide the training or supervision you need to adequately perform your job functions. You never know what you will be walking into when you walk into an SNF.

Direct Patient Care

Working at an SNF, you will spend 80-90% of your time during the day in direct patient care. For clinicians who want to do treatment, this is a setting for you. 

Unlike acute care where you might have to sit through patient rounds daily or home health where you are driving for hours a day, SNFs are about patient care.

You get to do treatment in SNFs and a lot of it. 

Patients and their families can become like family to you and you can develop close, professional relationships with your patients.

You can see progress because you get to work with patients for weeks or months instead of days.

This, of course, has its cons, which we will talk about under the “productivity” and “difficulty to leave direct patient care” sections below.

Leave Work at Work

What happens in an SNF stays in the SNF. Unlike home health, where you can bring documentation home and have to answer text messages and schedule while you’re at home, SNF work is just that, SNF work.

Work Closely With Peers

An SLP in an SNF often works closely with the other rehab department team members. Unlike a hospital or outpatient setting where each discipline may have its own department and office, SNF therapists tend to all share the same gym space.

Working closely with PT and OT can help you learn more functional skills as an SLP and can create opportunities for co-treatment and advancing goals based on physical needs. For example, PT may inform you that a patient needs to learn prompts to safely go from sitting to standing. You, as the SLP, can then work on that in your cognitive therapy.

Cons of Being an SLP in an SNF

Push for Productivity and Dollars

Productivity is the F word of SNFs. It’s a bad word that nobody wants to hear. 

To be brief, productivity is the amount of time per day that you are expected to be billing patients for treatment. I’ve worked in SNFs that have wanted me to be 95% productive daily! Meaning, I was expected to spend all but 24 minutes of my daily time directly with patients doing therapy. This does not include chart review, talking to staff, getting patients, or documenting after the patient leaves. 

THIS IS INSANE BUT IT’S NOT ABNORMAL!

Commonly, SNFs ask SLPs to be higher than 90% productive and 80% productivity seems to be on the lower end of the standards. Personally, I think that 75-80% productivity is a good number to be at over time in order to manage your caseload, be an educator to the staff, and not burn out. 

Consistent Pay Can Be a Challenge

One of the major pros of SNF work is that the hours can be flexible. But what if they are flexible when you don’t want them to be?

In comes hourly pay and productivity. 

It is very rare to find a salaried SNF job or to be an SLP in an SNF with guaranteed hours. More so than not, places will want you to work as little as possible and ask you to leave if there are no patients on your caseload to treat.

Thus, hours can vary and pay can be very inconsistent. 

You are on Dysphagia Island

In most SNFs, you will be the only SLP on staff most days.

You may have heard this term thrown around loosely in social media. If you don’t know what dysphagia island is, it’s real. It’s being secluded in a workplace where you are the only person who knows about dysphagia, treats dysphagia, and may have difficulty educating the rest of the staff about dysphagia. You are the only one who understands that bedside swallowing evaluations and thickened liquids aren’t the end-all-be-all of dysphagia.

Especially if you are a newer clinician, it can be difficult to be the sole SLP on staff. You don’t have anybody else to bounce ideas off of, chat with patients about, or understand your struggles.

“Building a Caseload”

Some SNFs don’t have the need for a full-time or part-time SLP, yet they lure clinicians in and say they should “build a caseload” from long-term care patients. While not always true, I find that “building a caseload” can refer to seeing patients who don’t have the potential to improve. There can be a lot of pressure in SNFs to pick up patients who are not appropriate for therapy. Then, there is pressure to keep them on caseload for prolonged amounts of time. 

In an SNF, you have to be your #1 self-advocate and advocate for what your patients do or do not need. 

Difficult to Access Instrumentals

Instrumental assessments are a crucial part of any dysphagia plan of care. In an SNF setting, accessing these assessments can be a challenge. Unlike an inpatient rehab or hospital where you might have FEES or radiology at your disposal, you have to outsource those tests in an SNF. You may have to deal with transportation logistics and administrators who don’t want to approve payment of these examinations.

The End-All-Be-All of the Referrals

One area where I really hit my head against the wall when working in SNFs was the eagerness to refer to the SLP for swallowing evaluation, but not wanting to get any other medical specialties involved, like GI, MD, or ENT.

Let me elaborate:

If somebody has dysphagia, they likely have another disease process at work. That could be a neurodegenerative disease, a respiratory disease, an esophageal disease, an infection (hello UTIs), or a process that changes the anatomy and physiology of the swallow, such as a cancer resection, facial trauma, etc. 

One thing that really got to me in the SNFs is that when the staff noticed somebody had difficulty swallowing, they wanted to refer to the SLP and THAT’S IT. No other workup or no other questioning of,

 “Why is this person who could swallow yesterday suddenly having difficulty today?”

In an SNF, it’s easy to refer to the SLP because we are mostly in house and do evaluations within 24-48 hours. I found that the staff liked to make referrals to us because it’s easy, versus exploring other options.

When I went to make referrals to an MD, I was greeted by lines of, “Well, the MD just wanted you to make sure he could swallow, so that’s it. What diet are you recommending?” 

When dealing with sick patients in the SNFs, or patients who need referrals to GI or ENT,  it can feel like you’re constantly fighting to get it. 

However, to turn a con into a pro, a knowledgeable SLP on staff can be the mover and shaker to get patients faster access to appropriate care.

Fighting Against Stereotypes

As I mentioned above, every SNF is different and you surely cannot judge one SNF by an experience with another. Same with SLPs. Every SLP is different and you cannot judge the work of one SLP by the work of another. 

Sadly, I find that SLPs can commonly be judged and face a bad rap in skilled-nursing facilities. 

“You just watch people eat.”

“You get paid to do that!”

“Your only solution is to put people on thickener.”

These phrases can be commonly uttered to the SLP in an SNF.

To combat this, I encourage the SLP in an SNF to always put their best foot forward and practice at the top of their license. Show other professionals what SLPs know and educate family, staff, and peers on what SLPs are doing. 

Be kind and educational; don’t be elitist or put people down for not knowing what we do.

Weekends/Holidays

As an SNF SLP, you may be expected to work weekends and holidays. While some SNFs have solid per-diem staff, others may expect you to be on call even during your days off. 

Difficult to Transition into Non-Clinical Care

In the pros section above, I mentioned how amazing it is that you get to spend most of your day in clinical care. However, as you spend more time in the field or advance in age, you might not want to spend most of your day in clinical care. You may want a cushy desk job or at least more time to document.

When working in an SNF, there really aren’t options for non-clinical work.

You either work as a clinician or you could work your way up management and be a director of rehab or maybe a regional director for an SNF company. Those last two positions are few and far between. This leaves a lot of clinicians not knowing what to do or where to go if they are burned out from patient care and the demands of high productivity in this setting.

Conclusions

Working in SNFs can be a great setting to be directly involved in patient care with a flexible work setting and team dynamic. However, the pressure to be productive and work alone on dysphagia island can be frustrating and lead to burn out. 

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