Clinical Network: The Challenges of Establishing a New Training Model

Cheryl Messick, Ph.D.

University Pittsburgh

In July of 1997 the Department of Communication Science and Disorders at the University of Pittsburgh closed the doors of the University Speech and Hearing Clinic. A Clinical Network system was initiated in August of 1997 in which first year graduate students in speech-language pathology and audiology are trained in community based programs (e.g., Children’s Hospital of Pittsburgh; University of Pittsburgh Medical Center - UPMC sites; and Mathilda Theiss early intervention center) under the supervision of University of Pittsburgh Clinical Faculty members. The clinical supervisors are employed by the University but are housed at the community sites. They are assigned clinical caseloads and provide practicum training to the students in the community sites. This training model teaches students assessment, treatment, case-management, and documentation skills in environments that closely resemble their outplacement settings and future employment sites. The students also experience the challenges of working in a managed health care environment from the very beginning of their clinical training. This paper includes a description of the conceptualization and implementation phases that provided the foundation for beginning a new clinical training program. It also includes a description of factors that facilitated the development of a new philosophy and program of student training.

Impetus for Change

The process of change in any organization can be challenging. Change often occurs through the vision of leadership compounded by environmental influences. In our case, there were numerous influencing factors that led the department to develop a new model of clinical training. First, there was a desire to provide the best clinical training program possible to enable students to meet the challenges of providing audiology and speech-language pathology services in the upcoming century. Dr. Malcolm McNeil (department chair) provided the initial vision for the Clinical Network based on his own experience as a clinical fellow at the Mayo Clinic. This vision included clinical teachers, who were experts, training students in real-life settings utilizing a scientific query model of clinical problem solving. The University of Pittsburgh is housed in an area of town where there were more than five major medical facilities each of which included its own Audiology/Speech Pathology Departments. Yet, only a small percent of our students participated in clinic experiences at those sites, and all of their experiences occurred in the last semesters of their graduate program.

Dissatisfaction with the ongoing model of clinical training provided the faculty with additional motivation to alter the traditional training format. By the late 1980s the University Speech and Hearing Clinic was experiencing myriad challenges. First, the clinic caseload lacked diversity in terms of the clinical disorders and ages of the clients. The pool of clients consisted primarily of school-age children with articulation and language deficits, and young adults with developmental disabilities. Clients who received services through medical authorizations from insurance companies did not tend to come to the University Clinic, but instead sought services in the surrounding medical facilities. Many of the clients in the University Clinic were "lifers" who were passed from one student to the next across the years. Such clients provided a safe training ground for students, but did not simulate the clinical challenges that the student would be responsible for when they began their outplacement or Clinical Fellowship Year (CFY) experiences.

The University Clinic also did not provide students with case management and documentation experiences that were standard procedures in the growing managed health care environment. For example, in the University Clinic students were not exposed to the concept of validating the need for services to the insurance providers on a quarterly or monthly basis. Another factor contributing to faculty dissatisfaction with the University Clinic model was that the department had no control of the budget as it was managed at the college level.

The primary catalyst for change, however, came from a University level decision to move the Department of Communication Science and Disorders out of the College of Arts and Sciences and into the School of Health and Rehabilitation Services. When this change occurred, the department lost the Speech and Hearing Clinic facility and was faced with the possibility of acquiring and paying for clinic space while simultaneously building a larger and more diverse base of clients. The prohibitive cost of space in the area of town surrounding the University propelled the department to consider the value of utilizing the excellent clinical programs in the University area as the training grounds for first year students.

As a result of the above influences the concept of a Clinical Network was developed. The Clinical Network includes a collection of varied community settings where University of Pittsburgh clinical faculty provide services while training graduate students in their initial clinical experiences. Students rotate through several sites during their first semesters and learn basic clinical competencies while working with varied clients. Learning in the Clinical Network is accomplished through participation in:

1. Observation and co-therapy activities;

2. Direct contact time with patients exhibiting a range of communication disorders;

3. Guided learning experiences; and Interaction in varied service delivery models (e.g., outpatient rehabilitation; community early intervention; acute care).

Through the Clinical Network, students have an opportunity to observe and work with a richly diverse collection of client disorders. For example, in addition to the more typical clientele, training activities include: participating in bedside swallow examinations and modified barium swallow testing for patients with dysphagia; fitting prostheses and learning to use alternative methods of vocalizing for patients who had laryngectomy; neonatal audiological screenings; complete audiological evaluations and assistive device dispensing; speech therapy for toddlers with apraxia; and intervention for children with autism spectrum disorders.

Conceptualization Phase

In the period of time between the initial vision of a Clinical Network and its implementation, the department worked towards refining the concept of the Clinical Network. Steps in the conceptualization phase of the project included a series of meetings with varied constituent groups who were involved with training graduate students. Additionally, collaborative relationships with training sites were initiated.

The initial set of meetings occurred at the department level where faculty and staff worked together to more clearly define the Clinical Network. These sessions were organized as brainstorming arenas and included both clinical and tenure-track faculty members. Since the department would soon lose the Speech and Hearing Clinic facility, the faculty became invested in the process of planning for the future. Additional meetings were held with outplacement supervisors and professionals in the community so that they too could contribute to the conceptualization phase. As a result of these discussions, the notion of the Clinical Network as a collection of sites within the community was developed. The Network would include sites within the greater Pittsburgh area that were open to the concept of training first-year students by pairing them with clinical faculty in real-community settings. It was critical that University faculty be the primary student trainers so that time could be allotted for client-contact hours, case management duties, and clinical teaching time while complying with ASHA regulations for clinical supervision.

As the concept of the Clinical Network was refined, additional meetings were held with staff members who were actively involved in clinical teaching. These meetings included clinical supervisors from the University Speech and Hearing Clinic, outplacement supervisors from the community at large, and staff from sites where the Clinical Network might be implemented. These meetings provided a format for the community-based sites to define the requirements that had to be met before they would consider embarking on this new clinical training project. One important notion that emerged was that the clinical supervisors would need to consider themselves first as providers of services to patients, and second as trainers of students. That is, the agencies needed a commitment from the University that the staff would provide quality services equal to that provided by the other staff at the site. Procedures that may have been implemented in the University Speech and Hearing Clinic merely for the sake of student training would not be possible. Instead, guidelines on effective and efficient service delivery, as influenced by managed health care, would be expected by the community sites. University clinical faculty members would also need to become integrated with the agency staff where they were housed. They would need to follow the guidelines and procedures of the site.

Current clinical supervisors began to realize that the Clinical Network would radically alter their jobs and responsibilities. Not only would they be housed at a new location, they would potentially have limited contact with the academic department staff and they would need to learn new clinical and administrative procedures. At some sites clinical faculty would be responsible for obtaining authorizations for insurance, a task not done with the typical University clinic clientele. Many of the part-time clinical supervisors elected to resign from their positions. The ones who retained their positions were flexible individuals who were willing to try the new model, even though they still believed strongly in the effectiveness of a traditional clinic training model.

The final steps in conceptualizing the Clinical Network focused on developing the collaborative relationships with target community sites so that formal agreements could be developed. It became apparent that the success of the Clinical Network hinged on our ability to have strong and lasting relationships with the settings where our first year students would be trained. Another series of meetings was held with personnel from each of the sites so that agreements could be worked out which would be amenable to both the University and to the individual sites. At each site a set of arrangements were made which defined the contributions and expectations of both the University and the community site. The initial formal contracts included a three-year agreement.

From the inception of a Clinical Network training program, Dr. McNeil believed the long-term success would be enhanced if the Directors of the programs where the Clinical Network took place had joint faculty appointments in the Department of Communication Science and Disorders. When faculty lines became open in audiology and speech-language pathology, directors of two of the speech and hearing hospital programs were encouraged to apply for the positions. Both of these individuals were people who had strong credentials and who would be excellent candidates for tenure-track positions from the perspective of the University. The Director of Audiology at Eye and Ear Hospital and the Director of Audiology and Communication Disorders at Children’s Hospital currently hold their primary academic appointments in our department and have been key members in our successful implementation of the Clinical Network.

Implementation Phase

Prior to the full-scale implementation of the Clinical Network, a pilot project was completed at Children’s Hospital of Pittsburgh for one semester. Six students had a one-semester assignment with a clinical supervisor who was a Children’s Hospital staff member. They worked with the clinical supervisor providing outpatient diagnostic and intervention services. The effectiveness of the pilot project was measured in multiple ways. First, the students’ performance in clinic was measured using the traditional student evaluation form that provided quantifiable measures of performance on clinical skills. The students also completed the traditional supervisor evaluation form providing feedback on the clinical supervisor as typically done each semester. The third measure included an oral interview by a tenure-track faculty member with each individual student. The oral interview provided anecdotal data focusing on the students’ judgement of the value of the experience. Students provided summaries of the clinical skills they had acquired and descriptions of the client disorders and services that they had provided. They also compared their experience at Children’s Hospital with that in past semesters at the Speech and Hearing Clinic. As a whole the students were extremely positive about their Children’s Hospital experience. The students cited the diversity and complexity of the client-base, and the value of practicing in a "real" clinic as two of the most positive characteristics of the experience. They also valued the clinical expertise of their supervisor. The fourth method of measuring the value of the pilot project consisted of a report written by the clinical supervisor who worked with the students. She described the strengths and weaknesses of the project and provided suggestions for improving the clinical training based on her experience with the pilot project students. She also identified possible administrative issues that needed to be streamlined in order for a faculty member to become oriented to the hospital procedures.

During the time that the pilot project was being run, steps were initiated to identify clinical faculty members who would train students in the Clinical Network. As noted earlier, a number of part-time Speech and Hearing Clinic staff had resigned, and a search was started to fill the empty positions. The search committees focused their search on hiring doctoral level clinical faculty who were interested in providing clinical training as their primary job responsibilities.

The University Speech and Hearing Clinic was closed July 1, 1997. The new Clinical Network was initiated in August 1997. That fall there were six new audiology students in the Clinical Network. The clinical faculty for audiology included two part-time staff from the University Clinic (FTE 1.1) and one new full-time staff member who had previously worked at two of the Network sites. The audiology clinical faculty were responsible for training the audiology students in their initial experiences and in training speech-language pathology students in their audiology practicum. In speech-language pathology there were 26 graduate students in the Clinical Network. They were supervised by five part-time staff (FTE 1.6) from the University Clinic and one new full-time clinical faculty member. A search committee was also formed to hire an additional full-time clinical faculty member for speech-language pathology.

During the first semester of operation the Clinical Network in audiology ran full-force, but the students in speech-language pathology earned a limited number of contact hours. Difficulties in speech-language pathology occurred as the staff transitioned into the new sites and needed to build a caseload of viable clients for student clinical experience. This change occurred at a time when the community sites were transitioning to obligatory authorizations for service before scheduling clients. With each succeeding semester the number of contact hours earned by students has increased, so that students currently earn approximately 22 hours for each academic credit of clinic.

When the Clinical Network was initiated it became clear to the clinical faculty members that there were many kinks that needed to be worked out at an administrative and procedural level. A Clinical Committee was formed and met approximately three times per month for the first year to work out the many challenges of the new training program. The Clinical Committee included three clinical faculty members whose jobs primarily included clinical training, one tenure-track faculty member, and one of the joint faculty members who directed clinical services at a community site. The chair of that committee reported directly to the department chair. The department chair also attended Clinical Committee meetings when requested, providing the committee with a direct means of obtaining feedback on issues and proposed solutions.

The Clinic Committee initially focused on describing the job responsibilities of clinical faculty and determining the manpower needs so that optimal clinical training could occur. Table 1 includes the workload formula that was created for a full-time clinical faculty member providing services in the community sites. Time was allotted for all aspects of the job including travel to and from the site. This formula allowed the Clinical Committee to make recommendations to the faculty regarding class size of incoming graduate students, and allowed clinical faculty to be scheduled with students in a realistic and fair manner. In scheduling students we typically assign one student to a faculty member for 2 day per week, for one academic credit of practicum. The Clinical Committee also worked on developing a new student evaluation system which focused on basic clinical competencies which needed to be achieved by students before moving to outplacement settings. This committee continues to be a working group, however, the frequency and duration of the meetings have decreased dramatically since the first year.

In conclusion, the development of our Clinical Network was a multi-phased process which occurred because of a desire for improved quality in clinical training, compounded by the forced necessity of change. In reviewing the history of the change, it is clear that there were a number of factors that helped us to achieve our goals. These factors include:

It may be helpful for programs to discuss these factors when considering any type of significant alterations in their programs. Creativity and a vision for change were critical forces that helped to initiate the process. Support from the department chair was critical throughout the development and implementation phases, and continues to be a factor in on-going evaluation and modification stages. At the implementation phase, it was critical that we have a group of dedicated staff who could move the vision into a workable reality. In our situation it often appeared very difficult for the staff from the old system (University Clinic) to make the transition to the new Clinical Network. The staff members who retained their positions were willing to change, but often became stuck implementing strategies that had been routine in the old clinic. In contrast, new clinical faculty members who came on board with a goal of starting the Clinical Network, seemed to have less difficulty shifting gears to implement the new system.

The final step in successful implementation of any grand plan is on-going evaluation of success. While the Clinical Network is a reality now, it continues to be modified and refined. Our current goals include continued efforts to maintain collaborative relationships with current sites and to develop relationships with new sites while expanding the diversity of our clinical program. We are also working on developing on-going supervisor training programs to ensure the quality of our Network clinical faculty and outplacement supervisors. We retain a solid focus on how we can create the best clinical training program possible, which was the starting point for this project!

Table 1. Workload formula for one full-time clinical faculty member.

ACTIVITIES

Time Per Student/Week

Time for 10 Students

Patient Contact Time

1.5 Hr

15 Hr

Clinical Teaching Time

1.5 Hr

15 Hr

Review of Plans/Documentation

.3 Hr

3 Hr

Case Management Time

.3 Hr

3 Hr

TOTAL TIME PER STUDENT

3.6 Hr

36 Hr

Travel Time Per Week

1 Hr

Department/Community Service

3 Hr

TOTAL TIME/WEEK

 

40 Hr/WK