Impact of Speech-Language Pathology Services for Long-Term Skilled Nursing Facility Residents with Dementia

Abstract

Speech-language pathology (SLP) services are integral to dementia care in skilled nursing facilities (SNFs), yet little is known about how those services are accessed, delivered, and evaluated for long-term care (LTC) residents living with dementia. SNFs are a major site of care for people living with dementia (PLWD) and a primary employment setting for SLPs, but SLP services have received limited attention in policy discussions about LTC quality. This dissertation examines SLP service delivery for LTC SNF residents with dementia through three linked papers addressing utilization, outcomes, and clinician decision-making. Together, these papers investigate who receives services and under what conditions, whether services are associated with measurable resident outcomes, and how organizational and financial forces shape clinical practice. In this dissertation, Chapter 1 presents the background on SLP services for LTC residents with dementia in SNFs, including the reimbursement context, evidence for SLP intervention, and gaps in current knowledge, as well as the conceptual framework guiding the dissertation. Chapters 2 through 4 are the three linked papers that jointly address the dissertation's overarching purpose. Chapter 5 is a conclusion chapter synthesizing findings across papers and discussing implications for clinical practice, workforce development, and policy. The first paper (Chapter 2) used Centers for Medicare & Medicaid Services (CMS) administrative data from 2018-2021 to examine factors associated with SLP service utilization among LTC residents with dementia. Clinical characteristics including dysphagia symptoms, comorbidity burden, and functional impairment were strongly associated with receiving services. However, utilization also varied with facility staffing, payer mix, and region. Service use declined following PDPM implementation and increased in response to higher facility COVID-19 burden, indicating that access reflects a complex interaction between clinical need, organizational context, and policy environment. The second paper (Chapter 3) used propensity score matched cohorts from CMS administrative data to examine associations between SLP services at admission and outcomes among LTC residents with dementia. Receipt of SLP services was associated with lower odds of hospitalization and reduced hazard of ADL decline. Higher hazards of decline in cognition, communication, and swallowing were also observed, a pattern more likely attributable to residual clinical complexity and measurement limitations than to harmful treatment effects. These findings suggest SLP services may support resident health and functional stability although the precise mechanism is not fully captured by available administrative measures. The third paper (Chapter 4) used a national clinician survey to examine whether SLPs reported modifying treatment decisions based on payer source. Nearly half of the 96 respondents reported payor-based differences in practice, particularly in session duration. Higher productivity requirements were associated with greater susceptibility to payor influence, while higher levels of dementia-related continuing education were associated with less. These findings supports that SLP practice in SNFs is shaped not only by patient need but by organizational and financial conditions.Together, these papers demonstrate that SLP service delivery for LTC residents with dementia in SNFs cannot be understood through clinical need alone. Reimbursement structures, organizational conditions, and clinician factors interact with clinical need to shape whether services are initiated, how they are delivered, and how their value is recognized. These findings have implications for clinical practice, workforce development, policy efforts, and patient outcomes to sustain and evaluate SLP services in LTC.