Kenneth E. Wolf, Ph.D.
Drew University of Medicine and Science
The first annual conference of the Council of Academic Programs in Communicative Sciences and Disorders in this new century focuses on The Challenge of Change. A truly apropos theme, as stability within the working environments for speech-language pathologists and audiologists appears to be a distant memory. In fact, if there is one thing that is constant, it is that change will occur, embraced or not. Therefore change is not the issue nor even the challenge, but rather managing the impact of that change and how to be prepared for its inevitability. The transformations within the American health care delivery system provide an environment to develop and test knowledge, skills and attitudes that may have been never before encountered, not only for the graduates and educational programs in communicative sciences and disorders, but for all health care professions.
The most dynamic and dramatic decade in history of the United States health care delivery system occurred at the end of the 20th Century. And some, such as the Pew Health Professions Commission (O’Neil, 1998) suggest that what has happened thus far is only a prelude to the future. Therefore, preparing graduates to practice in the immediate and distant health care environment requires educational programs to not only be aware of these changing dynamics, but also to anticipate additional modifications and expectations to come. Students must be instilled with a commitment to life-long learning regarding content areas within their profession along with skills for continual retooling as professionals. And most importantly, academic leaders and faculty have to provide leadership and modeling for succeeding in an environment that is not likely to remain constant.
The evolution of the health care delivery system is further taxed by factors outside of health care arena. The nation has greeted the 21st Century with the largest generation of students, an increasing cultural diversity, and insatiable thrust for technology. Are educational programs in communicative sciences and disorders prepared to meet these simultaneous multi-faceted variables? Understanding these core factors is a necessary prerequisite to successfully meeting the Challenge of Change.
The Modern Health Care Delivery Environment
The cost of providing needed and desired health care services spiraled out of control in the late 1980s and early 1990s (Kreb & Wolf, 1997). Changes have taken place not only in how services are paid for, but also who controls access to and availability of those services. A demand for accountability has emerged for all levels of services (Wolf, 1999).
Payers are seeking results that give the best possible outcome, for the least amount of money, in the least amount of time. The transition to data-based accountability began several years ago when managed care organizations (MCOs) began to deny requests for services, or deny payment after services had been rendered, unless those services were accompanied by appropriate justification. Health care providers (including speech-language pathologists and audiologists) could no longer order procedures, or perform procedures, simply because they felt that it was in the best interest of the patients. Providers now had to prove that such services were going to make a difference in the way the treatment was performed, and in the eventual outcome of that treatment. Mature organizations said “if you wish to perform a certain procedure, show us the data that substantiates a positive impact on the results of care.” When we as providers failed to produce such data, MCOs refused to pay for services (Wolf, 1999).
In response to this accountability-driven system, most health care professions initiated rapid attempts to collect treatment outcomes data. ASHA has been in the forefront of such efforts; however, the establishment and creation of outcomes measuring instruments are very slow and very expensive. The ASHA project which began seven years ago, still moves forward today as the National Center for Treatment Outcomes and Cost Effectiveness (ASHA, 1999a). In many regards, ASHA is ahead of other professional organizations. The purpose of collecting the data is not simply to have data, but to demonstrate how the services provided actually impact care. It is important to remember that MCOs are administered and managed by business people and if it can be demonstrated that it is in the best financial interest of the MCO to provide services, such services will in fact be provided. The objective of managed care is not to deny services, but rather to get the maximum health care value for its dollar spent (Wolf, 1997a). (See Kreb and Wolf  for a detailed discussion.)
A new approach to health care delivery has been emerging throughout the 1990s known as evidence-based medicine. The process is applicable to all aspects of health care delivery and has evolved into evidence-based health care (EBHC) (McKibbon, Eady, & Marks, 1999). The practice de-emphasizes practitioner intuition and unsystematic clinical experience. Instead, EBHC requires that decisions are reached through the systematic examination of evidence from clinical research and is dependent on the scientific method. The art of medicine, and treatment based on knowledge of diseases and disease processes, holds a less prominent position in the clinical decision-making process. Although the ultimate treatment is delivered to an individual patient, EBHC is based upon populations and is deeply rooted in epidemiology. EBHC demands that practitioners be efficient and effective searchers of the literature. Once that literature is identified, it must be critically appraised, not only for its scientific and clinical merit, but also for its applicability to the target patient or population. An EBHC approach identifies a priori rules for such literature selection and evaluation. Thus, using an EBHC approach provides justification for services that is supported by clinical evidence and literature while adhering to a consistent set of application standards. Practice guidelines and clinical pathways evolve directly from evidence-based practice. Such a process creates a bridge from treatment efficacy to treatment effectiveness (Guyatt & Rennie, 1993; Kreb & Wolf, 1997; McKibbon et al., 1999; .Sackett et al., 1997).
Practice guidelines delineate systematic processes to assist the practitioner, and the patient, in decisions about appropriate health care for specific clinical circumstances. Guidelines are used to translate knowledge into the practical realm of clinical decision-making in unambiguous and precise terms. Guidelines are combined with clinical pathways or algorithms that are used to coordinate the day-to-day progress of patients. These algorithms are used to decide when to stay the clinical course, or when to vary and in what direction. All decisions lead to specific courses of action with predetermined measurable outcomes, which in turn direct treatment to the next portion of the pathway (Poplin, 1998; Wolf, 1999).
Benchmarks are established through the use of practice guidelines, based on evidence with expected outcomes. Benchmarking is the collection of a database to compare outcomes for an individual patient to those for the clinician, the facility, the region, or the nation. Such an analysis provides a quantifiable measure of expectations and accountability compared to an existing clinician, facility, regional, or national standard. In other words, the results of services rendered to a specific patient can be compared to a larger aggregate national or local or specific database. Such comparison can be used as a measure of how successful treatment is at a certain point in therapy, and what to expect with continued treatment. These benchmarking procedures can be used for the individual clinician against their aggregate pool of previously seen patients, or against a larger pool for the specific facility in which they are working, or even against a national database provided from many clinicians seeing many patients (Kreb & Wolf, 1997). Benchmarking may also be used internally to assess productivity standards (Wolf, 1997a; in press).
In summary, the contemporary health care environment is demanding accountability from all providers in terms of time, cost, and real world functional outcomes. It is seeking to hire health care providers who understand, accept, and embrace these stipulations. The practice environment that current and future entry-level health care providers are entering is quite different from that in which their faculty and mentors trained (Wolf, 1997b). Consequently, these new demands intensify a mounting pressure on both professionals and health career educational programs that are responsible for educating providers.
The Health Care Workforce
Currently there are approximately 10.5 million health care workers in the United States representing over 200 professions and occupations. Ruzek et al. (1999) and The Center for Health Professions estimate that over 60% of that workforce are allied and ancillary health workers. The report concluded that these workers are impacted the greatest by the changing health care delivery system. They are asked to be more flexible, more tolerant of uncertainty, and more capable team members. Simultaneously, educators are having difficulty preparing workers with the breadth of appropriate skills required to be fully functional in this volatile system.
Speech-language pathologists and audiologists are obviously a component of that workforce. Mid-Year 1999 statistics show there are over 97,000 speech-language pathologist and audiologist members in the American Speech-Language-Hearing Association (ASHA), an overall growth of almost 3% in the past year. Females dominate the profession (92.2% of the total membership) with male membership continuing to decrease (7.8% in 1999). Membership from racial and ethnic minority groups (7.5%) continues to lag behind that of the distribution in the American population (ASHA, 1999b; Ruzek et al., 1999). The overwhelming percentage of speech-language pathologists and audiologists are employees. Median annual salaries are in the mid-$40,000 annual range (ASHA, 1999c; Ruzek et al., 1999). And as general rule, speech-language pathologists and audiologists are not risk-takers, but rather seek security.
The Vector Workforce Study (1999) assessed the current and future supply of ASHA-certified speech-language and hearing professionals, and the current and future demand for these same professionals. They concluded that both professions are currently in balance, meaning that there is neither an oversupply nor a shortage of certified speech-language pathologists and audiologists. However, given that the rate of annual growth in ASHA-certified providers has been almost 5% annually over the past 10 years while the general population has only grown at about 1% per year over the same period, combined with the average number of students who enter programs each year, the supply of professionals is growing faster than the projected demands for both professions. Depending on the projection scenario, the excess supply will occur some time after 2010. The authors point out that demand can not be equated with need. That fact has caused some to question the study (Deal, 2000). The study also did not take into consideration the increasing cultural diversity of the nation nor the changing role of audiology that is likely to take place with the implementation of universal newborn hearing screening programs.
Other factors and issues that will affect the future workforce in speech-language pathology and audiology are being discussed in the larger health care arena. The Pew Commission (O’Neil, 1998) suggested that health professions must reconsider how they best add value to the health care delivery system. Among their recommendations were that professional numbers be sufficient to meet the public need, but not oversupplied in a manner that produces excess costs. They were critical of the failings of professional education in forecasting levels of supply and demand. The Pew Commission Report also advocated restructuring the way that the health care professions are regulated so that professional credentials fit with the goals of the emerging health care system. Further, all health care professionals would be expected to demonstrate interdisciplinary competence as a way of expediting service delivery, avoiding duplication of service, and eliminating “turf battles.” Finally, it was recommended that schools must realign training and education to meet the changing health care delivery needs of society and focus on assuring that competencies are met through rigorous testing. While the Pew Commission Report was not specifically about speech-language pathology and audiology, its implications were directly relevant.
Several of the conclusions and recommendations offered by Ruzek et al. (1999) were similar to that of the Pew Commission (O’Neil, 1998), calling for greater cooperation between health care delivery organizations, workers, and educators who have historically set policies in isolation from each other. They stated that accreditation and licensure standards do not reflect the current thinking regarding quality improvement and demonstrated competencies. The most damaging conclusion was that contemporary educational system has not offered a product that meets the needs of the health care delivery system. Reinventing the future of allied and ancillary health requires more involved partnerships which address educating a workforce to meet the service needs of patients, employers, and the health care system, rather than that of the educational institutions. Speech-language pathologists and audiologists did not receive much attention in the report that gave greater emphasis to physical therapists and technicians. In fact, ancillary workers like unlicensed assistive personnel and custodial and food workers were given more attention than speech-language and hearing professionals. Nonetheless, the conclusions were important to the future of communicative sciences and disorders educational programs and their graduates, for they pose questions and offer challenges that must be considered to assure future viability.
Speech-language pathology and audiology have evolved as autonomous professions. However, reports such as those of the Pew Commission (O’Neil, 1998) and the Center for the Health Professions (Ruzek et al., 1999) have spawned questions within the health care payer, watchdog, and legislative arenas. How do others in the health care environment view speech-language pathologists and audiologists, and how will that impact positioning on the health care team? Are speech-language and hearing professionals viewed as equal members of the professional team or as ancillary workers who support the medical and nursing professions? That positioning will affect the professions, professionals and have retrograde impact on educational programs.
The role of legislative action has been a crucial factor in improving the public’s access to speech-language and hearing services, and subsequently paramount to the growth of the professions. Nowhere has that been more evident than the recent legislative successes in newborn hearing screening and delaying the implementation prospective payment system and the $1500 cap for therapeutic services (Moore, 2000). The precedent was established in the 1970s with the historical success and current efforts regarding mandates for services under Individuals with Disabilities Education Act (IDEA). Although the professions now have been assured either prospective payment or retrospective reimbursement for services with such legislation, access to services remain vulnerable to public policy and political climates (Wolf, 1992). Professionals in communicative sciences and disorders have enjoyed the comfort of perceived security because of legislative mandates. Unfortunately, the creation of a mandated need for existence causes an inherently sustained vulnerability, especially when that existence is subject to political ebbs and flows. Speech-language pathology and audiology may be better served by creating value rather than mandates for our services. Are speech-language pathology and audiology services valued by the health care consuming public primarily because of mandates for third-party or government payment? Are the services desired and perceived to hold value only if some one else is paying for the services, or are consumers willing to forego other valued services and products to be able to pay for speech-language or hearing services? The professions need to be viewed in such positive light that individuals are willing to undergo some financial sacrifice to receive services, creating a high degree of value. Until that perceived value is achieved, marketing efforts are at-risk of being compromised and falling short of their objective (Wolf, in press). Creating value begins with university programs, faculty and the behaviors that students witness.
Factors Driving Change
There are several factors external to the health care environment that
will have a significant affect on health care delivery and the educational
programs that prepare future providers. Table 1 lists these factors:
the changing demographics of the United States and the explosive use of
information technology. Given the changing forces in the general
environment, as well as the historic patterns within speech-language pathology
and audiology, what can be expected for the future? The balance of
this paper will address issues that currently exist and that are likely
to influence the future of communicative disorders in the health care arena.
|Table 1: Critical Factors Driving Change|
The Baby Boomers, those born between 1946 and 1964, were the largest and loudest generation in history. Twenty-nine percent of the current United States population (77.2 million individuals) were born in this period (US Census Bureau, 1990) After a decrease in the population growth rate between 1965 and 1976, came a new, larger and louder group, sometimes referred to as the Baby Boom Echo or those born between 1977 and 1997. The Echo has produced approximately 81.1 million children, or 30% of the current population. This newest generation currently presents more immediate challenges to the education system (including the university community) than to the health care delivery system, as it is an age group that for the most part enjoys the luxury of good health. However, the Echo, or Net Generation (Tapscott, 1998) exemplifies a new learning style that demands rapid and continued access to the latest information as well as interactive presentation and exchange. This generation represents those who will be entering communicative sciences and disorders educational programs shortly and for the next 20 years, and then into the health care workforce where it is likely that they will drive additional changes. (The Baby Boom Echo will be discussed in greater detail later under the section on Information Technology.)
And not to be forgotten is the rapidly increasing numbers of elderly individuals in this country. It has been widely reported that there are projected to be nearly 60 million Americans (19% of the total population) age 65 and older by the year 2025 (National Center for Health Statistics, 1984). Increased aging is commonly associated with greater demands for health care services including speech-language pathology and audiology. In fact, hearing loss has been found to be one of the top four chronic conditions experienced by older individuals, exceeded only by arthritis, high blood pressure, and heart disease, and followed by orthopedic problems, cataracts, chronic sinusitis, and diabetes (Popelka et al., 1998).
Thus, each of these age groups will present specific challenges to the educational programs in communicative sciences and disorders and their graduates. As a result, each generation must be viewed distinctly in terms of diagnostic, therapeutic, and research needs that lead to improved outcomes.
American society has become increasingly defined by diversity over the last half century. Those who have immigrated have enriched mainstream culture in many ways, such as the expanded variety and range of foods, music, and languages found in this country. They have also brought attitudes, customs and expectations about society in general, and health care and education specifically, that often present challenges to the health care and education systems which ultimately may have adverse affects on service delivery outcomes (Wolf & Calderón, 1999).
This explosive emergence of minority populations over the last twenty-five years that has occurred simultaneously with the growing elderly and Baby Boom Echo populations ( Battle, 1998; US Bureau of the Census, 1990). The influx of people from Asia, Africa, the Caribbean, Central and South America, and the Pacific Islands represents a migratory pattern that is in striking contrast to the last great migration of the 1890s-1920s, which emanated primarily from Europe. At the mid 20th Century, about 97% of the U.S. population was of European origin. Currently, minority populations account for approximately 24% of the total population and over the next ten (10) years, they are projected to account for 30%. These projections estimate that by 2050 the non-European origin population will constitute 47% or more of the total U.S. population. Phrased differently, there is not likely to be a majority population within the next 50 years.
Traditionally, minorities were defined as that segment of the population who were of non-white ethnicity and/or race, and who comprised a minor numerical portion of the total population. Consequently, early epidemiological studies used the categories white and other. In the late 1970s to early 1980s, the Other category was separated into Black, Hispanic and Native American, and initial efforts began to collect and report data. (The fact that one category was based on skin color and the others were based on national origin is beyond the scope of this paper.) However, many of the terms used to define groups and sub-groups overlapped, such as race versus ethnicity, or failed to provide specificity such as Latino versus Hispanic or African American versus Black. For example, there are 500 federally recognized Native American Tribes, 23 different countries of origin of Asian/Pacific Islanders, 5 major places of origin for Latinos, and a diverse African-American population, all living in the United States. To homogenize these individuals into two, three or even a half-dozen groups, not only minimizes their uniqueness and prevents understanding of customs, traditions and beliefs, but also has had detrimental impact on understanding the determinants of their health and education status (Wolf & Calderón, 1999).
The extent of cultural diversity today presents powerful challenges to our health systems. The lack of adequate preparation to meet this responsibility is reflected in the adverse affects on the quality of care, quality of life, and quality of education for these populations. Consequently, while the crippling effects of many diseases and disorders has been diminished, vulnerable populations (particularly minorities and the poor) have not benefited equally (Fernandez et al., 1998). Members of minority groups lag behind their majority counterparts in almost all health measures from life expectancy to chronic disease rates. The incidence and prevalence of many diseases is greater, and preventable and curable diseases often present at more advanced stages due to reduced access to care in the minority populations. Further, the gap is widening, rather than narrowing! Poorer health status is not attributable to any single factor, but rather many, including but not limited to attitudes and beliefs, life styles, access to services, knowledge (about health and education), poverty and provider understanding.
The relationship between culture and health is particularly relevant to underrepresented racial and ethnic minority populations whose perceptions of illness, and attitudes toward seeking health care, have been demonstrated to differ considerably from that of the majority. The health status outcome of this relationship is further complicated by the tendency for minority groups to be uninsured and live in poverty (Drake & Lowenstein, 1998; Komarony et al., 1996).
Physicians from ethnic minority groups are more likely to treat a patient population of a similar ethnic group. Furthermore, members of ethnic minorities are more likely to consult physicians of a similar ethnic background (Drake & Lowenstein, 1998). However, the growth in numbers of providers from culturally diverse populations has not been able to keep pace the rate of growth of those populations, and the disparity continues to widen. Thus, if the challenge of providing competent care to culturally diverse populations through training a workforce that is reflective of the racial, ethnic and socioeconomic characteristics of the population can not be met rapidly enough, then all providers (regardless of cultural background) must receive cultural competency training both in their primary as well as their continuing education experiences (AAMC, 1998; Cohen, 1997). However, unlike in the past when diversity training was often limited to racial awareness, cultural competency education must focus on preparing students, educators, and providers on ways to effectively manage and interface with diverse patients and colleagues (Welch, 1998).
Cultural competence is a multi-dimensional concept that encompasses cultural awareness, cultural sensitivity, cultural tolerance, and the understanding of how the cultural idiosyncrasies of a given population affect their overall health status. Attaining cultural competence is a process that begins with the recognition of the need for continued introspection on the part of providers, and the development of attitudes that will foster an awareness of their own value systems. Furthermore, it requires the development of proficiency in acquiring pertinent knowledge and utilizing that knowledge to make appropriate assumptions. These assumptions can then serve as the basis for making meaningful inferences about a culture other than one’s own (Calderón, Wolf, Baker, & Edelstein, 1998). Critically, cultural competence is well beyond knowing the patient’s language, but truly understanding the patient’s culture, beliefs about health care and knowledge of how the health care delivery system works. And finally, cultural competence includes knowing when, as a provider or educator, to seek cultural assistance and advice. The significance of cultural competence has become so prominent that the Health Care Financing Administration (HCFA) in September, 1998 proposed new regulations mandating that states establish cultural competence guidelines for Medicaid contracted health plans.
The Office of Minority Health Public Services (1999) stated that cultural and linguistic competence suggested an ability by health care providers and health care organizations to understand and responded effectively to the needs of all patients they encounter. As a result, 14 recommendations have been put forth to assure equal health care access for diverse populations. These recommendations range from development of skills, knowledge, attitudes, and behaviors of providers, support personnel, managers and administrators to patient education and strategic planning of health care organizations. All individuals from the front office personnel to administrators, from patients to providers and policymakers are targeted in the recommendations for cultural competency education. Finalized guidelines are anticipated in the Fall of 2000.
There is little reliable data on the incidence and prevalence of communicative disorders among culturally diverse populations in the United States, although there have been suggestions that there is a greater prevalence among ethnic and racial minorities (Battle, 1998). If however, the prevalence is consistent with the general population, then approximately 6.2 million Americans from culturally and linguistically diverse backgrounds would be expected to have a communicative disorder. Likewise, in their review of the literature Wolf and Hewitt (1999) found sparse data on hearing loss among culturally diverse populations, and that there was little education and information about hearing loss available to these populations. How do individuals from culturally diverse populations perceive communicative disorders and how are services accessed?
Do speech-language pathologists and audiologists understand the impact
that culture has on the delivery of health care and educational services?
The professions of speech-language pathology and audiology have demonstrated
a commitment to understanding the impact of culture on clinical practice
and research, as well as the need for education (ASHA, 1991). However,
can the majority, or even a significant percentage of speech-language pathologists
and audiologists answer the above and similar questions in the affirmative?
If the challenge presented by the Pew Commission and others (ASHA, 2000;
Office of Minority Health, 1999; O’Neil, 1998; Ruzek et al., 1999) for
health education programs to make racial/ethnic diversity a higher priority,
then perhaps current efforts may require revision, re-evaluation, and even
greater commitment to achieving cultural competence for students and existing
professionals in communication disorders. All professionals, regardless
of their cultural background need more intense training and education in
order to meet and maximize the service delivery needs of the expanding
diversity of our population. Understanding one’s own culture, majority
or minority, is a start, but does not generalize to all others (Wolf &
The Baby Boomers were also the television generation. Not just for entertainment like I Love Lucy, Amos and Andy, The Ed Sullivan Show or The Mickey Mouse Club. Television shaped the events of the nation and the world, like the war in Vietnam and the Watergate debacle. It became a tool of entertainment, politics, public policy, social commentary, and education. And with its companion equipment, the video tape recorder, anything could be preserved and replayed or rebroadcast. The technology of choice for the Baby Boom Echo is not the television, but rather the Internet. Tapscott (1998) refers to this group as the Net Generation. Computers and communication via the Internet have become an integral part of lives faster than another technology. It took radio thirty-eight years and television thirteen years to enter fifty million American homes, but only five years to reach that level of penetration for the Internet. Last year 48% of American adults (ninety-seven million people) used the Internet (Goldsmith, 2000). In fact, it is now estimated that there are more data than voice transmitted over telephone lines.
The use of information technology has become a mainstay within the health care delivery system. Computers are used not only to improve the operations of a facility, integrating scheduling, billing, inventory and payroll, but also for scientific and clinical purposes. Access to the information superhighway via the Internet has become an integral aspect delivering care, used by patients, providers, payers, educational and government agencies. Patients use the Internet to gather information about diagnosis and treatment, and bringing that information to their health care providers (McKibbon et al., 1999). It is estimated that seventy million Americans sought health care information on the Internet in 1999 (Goldsmith, 2000). Providers must know what the patients are reading, and whether that information is or is not a viable option. Additionally, providers are turning to the Internet for literature searches and information that is applicable to their practices, as well as to receive their professional literature via electronic publishing.
The National Library of Medicine Medline database is growing at over 30,000 citations per month. As a result, clinicians often feel overwhelmed in their attempts to not only stay current, but also in deciding what literature to incorporate into their practices (Guyatt & Rennie, 1993). Evidence-based health care (EBHC) described earlier, provides a mechanism to do both, maximizing precious reading time by giving the greatest attention to the most relevant articles and research which has a good chance of being directly applicable to a patient. Searches through these vast databases are accomplished more rapidly and efficiently using high speed computing and the Internet. And many of the articles selected are now even available online, some even at no charge (Subcommittee on Computing, Information, and Communications R & D, 1999).
Outcomes data that are demanded by payors of health care are not always easily attained. However, accessibility is rapidly changing with the use of information technology commonly referred to as medical informatics. The use of new technologies to access data, as well as collect data about patient satisfaction, treatment outcomes, treatment methods, has grown exponentially over the last 10 years. These technologies include internal databases that may be unique to an individual provider, facility, or managed care organization. Accessing such databases (public or privately managed) has been greatly facilitated by Internet technology and is a rapidly growing activity within many managed care organizations. The use of such Internet technologies allows many organizations to pool data and thus increase the size of the database that they may access. Access to information through the Internet via computer is no longer a luxury but a requirement for successful practice in today’s outcomes driven world. The computer is now a basic tool required in the provision of health care (Kreb & Wolf, 1997).
Clinically, electronic medical records are under development in many facilities and will be common in the near future. For example, a statewide medical record information system is expected in California sometime around the year 2005 (Managed Care Improvement Task Force, 1998). Finally, many MCOs are requiring that patient data be used to build databases, leading to internal benchmarks. A more in depth discussion of this topic may be found in Lindberg (1995), Lindberg and Humphreys (1996), Subcommittee on Computing, Information, and Communications R & D (1999).
One of the pace setting health care applications using the Information Superhighway is telemedicine or e-health. The provider and the patient are separated by some distance, often in different buildings or even different cities, but are linked to one another using information technology. In this manner, health care services can be delivered to locations where access is difficult such as rural areas of the country. Access may even extend across national borders. Another application of telemedicine has been to provide services to the prison population without the need for a clinician to travel to these remote areas. Through telemedicine, the prison population may receive more frequent and less expensive health care services. Similar applications may be quite attractive in large congested urban centers, helping to reduce costly travel (and/or commute) time and relieve traffic (Flowers et al., 1997; Sanders, 1996). A reasonable application for speech-language pathology may be in the area of home health delivery (Sanders, 1996). Patients may have the appropriate technology in their home or receive it on a loan basis. Therapeutics can be delivered and monitored, on-line or off-line, through the use of information technology. By using such application, the need for travel and face-to-face therapy may be reduced. Such applications could reduce costs and improve access, while opening a new and vast field of study (Kreb & Wolf, 1997).
Opportunities for educational applications using technology and the Internet are materializing rapidly. Television applications touted by the Baby Boomers were static reproductions of events, that required passive learning by the viewer. The new technology takes full advantage of the interactive nature of the world-wide-web. Self-directed, self-paced distance learning is becoming common in various academic disciplines including speech-language pathology and audiology. The technology is being used for undergraduate and graduate education, as well as continuing education. Continuing education that requires passive learning (listening to a lecture) has been found to be ineffective at altering practice behaviors (Davis et al., 1999). However, the concept of Just-In-Time continuing education may offer greater benefit. If an expert were consulted regarding an immediate specific clinical problem or question using information technology as a vehicle, then not only would the patient benefit, but possibly so would that clinician who has an increased probability for retaining the information for future application because it has clinical relevance. Why not provide continuing education credit for such activity? Rather than getting continuing education in large 1-3 hour blocks, continuing education could be accumulated as clinically needed in smaller (i.e., 10-15 minute) units. Such approaches are being explored in medicine and maybe relevant to communicative sciences and disorders.
Access to information technology, and specifically the Internet, unfortunately is not equally distributed across the United States, and in fact, race, age and income are major factors. Eighty percent of the nation’s households with incomes over $75,000 have personal computers, compared to only sixteen percent of the households with annual incomes under $20,000. Less than 12% of the African American homes have Internet access, compared to more than third of the white homes (U.S. Department of Commerce, 1999). Further, only 15% of those over 55 years of age use the Internet. Those populations with the poorest access and/or willingness to use the Internet are also those who are at the greatest risk to have the worst health care outcomes. As more services are offered electronically, these at-risk populations will become more vulnerable and are at heightened peril of falling even further behind. For example, the elderly’s need for health care and information may become compromised by their limited access or willingness to use technology (Goldsmith, 1999).
Are students entering communicative sciences and disorders programs with information technology skills needed to not only learn present day curricula, but also to be effective life-long learners? Are programs adapting the presentation of curricular materials to accommodate the interactive demands of the Net Generation? Every year it seems that the students entering college are more advanced in terms of their grasp of information technology, and that would certainly be confirmed by the Tapscott’s (1998) survey. However, there may a widening disparity between the who are advantaged and those who are not. Both the Pew Commission Report (O’Neil, 1998) and the Center for Health Professions report (Ruzek et al., 1999) reported the changing demography in California schools, both postsecondary and K-12. Most of the individuals enrolled in postsecondary education in the 1960s were full-time white males between 18-24 years of age. Currently, the majority are women from culturally diverse backgrounds. Twenty-five percent of the school age-children in California are limited English Proficiency. The percentage of freshman entering the California State University system who require remedial math (54%) and remedial English (47%) is at an all-time high. Further, there is a higher attrition rate among African American, Hispanic, and Native Americans students in the health careers education programs. Thus the entry level skills that will contribute to educational success among the individuals critically needed to improve health outcomes may not be a realistic expectation given the current environment. Ruzek et al. (1999), therefore, have called for not only strong recruitment efforts from culturally diverse backgrounds, but also to provide support for those individuals to successfully matriculate through these programs.
ASHA Focused Initiatives 2001
ASHA has developed Focused Initiatives, special projects within the annual budget with a small amount of dedicated funding. The Focused Initiatives for any given year are determined by the ASHA Executive Board, at the direction of the Legislative Council following identification of issues from the membership. There are two focused initiatives for 2001: 1) revolves around the use of advance information technology in speech-language pathology and audiology; 2) involves the increasing cultural diversity of our country and its impact on clinical services and education. Thus the American Speech-Language-Hearing Association not only agrees that these two areas will be critical factors affecting health care in the immediate future, but also that these factors merit special attention within the association’s planning efforts for the coming year. Look for more information and reports on both of these focused initiative over the next 18 or so months.
Impact on University Programs
There is very little information about the impact of managed care on university training programs in communicative sciences and disorders. However, the medical education literature suggests that only (18% ) medical schools required their students to have an HMO experience, forty-four percent (55) of 125 medical schools required that some of their students have exposure to an HMO (Veloski et al., 1996). In general, medical schools used managed care organizations because they offered rich clinical sites with good patient bases to expose to students. MCOs were not usually selected because they were unique managed care organizations, nor to expose students to the managed care environment. In other words, sites were selected because that was where the patients were found, not because it was a good site for teaching about that health care delivery environment.
Health care industry leaders estimate that it takes at least a year or two of post-residency experience before newly entering professionals are fully capable of practicing in a managed care environment. Phrased differently, learning how to be an effective provider within the managed care environment currently falls in the category of on-the-job-training, because of the lack of exposure, training, and experience that is currently available in many academic medical centers. Naturally, the value of the product of the academic institution whose graduates are ready to practice in the current health care world will be higher than those who do not prepare their graduates in such manner. Simply stated, graduates who are prepared for the managed care world will have greater market appeal to future employers (Wolf, 1997b).
The contemporary health care environment is seeking to hire health care providers who understand that the current health care delivery model is different from what was developed and used by previous generations (Blumenthal & Thier, 1996). MCOs want providers who fully grasp the new managed care culture, including finances and structures. Providers who understand resource allocation, resource management, and risk management have an advantage over those who do not. MCOs also expect their providers to understand managing the health of populations, not just the illness and diseases of individuals. In addition, the health care provider in today’s environment must be knowledgeable about information technology and the Internet, comfortable with evidence-based health care (McKibbon et al., 1999), and posses the skills necessary to provide culturally competent care (Office of Minority Health, 1999; O’Neil, 1998; Ruzek et al., 1999; Wolf & Calderón, 1999). Managed care organizations want providers who know more than just their professional discipline, but have an understanding of social and behavioral sciences, as well as a comprehension and knowledge of bio-ethics (Wolf, 1997b).
As the knowledge base required to provide quality health care continues to grow, there has been a growing voice that the credentialing of professionals should move to a process of renewed demonstration of competencies (O’Neil, 1998). Further, the Pew Commission has identified Twenty-one Competencies for the Twenty-first Century with focused attention on specific areas such as ethics, evidence-based culturally competent care, application of new knowledge, critical thinking and problem solving skills, improved access to health care for those with unmet needs, culturally competent care, partnering with communities and industry, increased use of information technology, working in interdisciplinary teams, ensuring care that balances individual, professional, system and social needs, and practice leadership. These core competencies are consistent with those expressed in a briefing paper offered by ASHA Special Interest Divisions 10 (Issues in Higher Education) and Special Interest Division 11 (Administration and Supervision) (ASHA, 2000). These topic areas are likely to demand greater attention and be disbursed throughout the curricula in the near future.
Allied health educational programs have been criticized that their product does not meet the needs of industry they serve. A reason suggested has been that allied health faculty, isolated from the professional realm of the care delivery system, have few vehicles with which to understand the changes occurring in the emerging health care system (O’Neil, 1998; Ruzek et al., 1999). If faculty who teach clinical courses were required to earn a portion of their income from direct practice, perhaps this criticism could be eliminated. Are the faculty in communicative sciences and disorders education programs prepared to earn any portion of their income from clinical practice? Perhaps it is time to consider partnering with clinical service providers in private practice and hospital environments, not just as a practicum site, but as true colleagues and partners.
Faculty within the university programs will also need to actively step up and lead the way in the creation of value of communicative sciences and disorders services. If speech-language and hearing services continue to be dependent on legislative mandates, the professions will remain vulnerable to political climates. Having a need for services is just a beginning. Value must be created for those services to the extent that all payers, including the ultimate consumer, are willing to pay for them. Through the creation of such value, the professions may begin to develop greater autonomy and attract a different type of student who is more adventuresome and willing to take some risks. Simultaneously, the pool of potential new faculty for the future then broadens.
Are faculty members, department chairs, deans and universities ready and willing to embrace the changes that are needed to produce the next generation of speech-language and hearing professionals? Are they prepared for professions that are committed to change through life-long learning, that judge productivity based on outcomes rather than number of hours worked or classes completed? Are they prepared to earn their income through the provision of direct services, to partner with existing clinicians to expand teaching and research experiences, and to develop and demand cultural competence? And all in a technological world that is changing faster than at any time in history? Those are the challenges that the current health care delivery system is posing to all educational programs, not in the future, but now!
The Challenge of Change in today’s health care environment is indeed vast. Those challenges are driven by the greater needs and changes occurring within American society as a whole. No longer can health care or education be considered in isolation. New strategies, partnerships and expectations are required to stay viable as educational entities. Communicative sciences and disorders programs must not only produce graduates who can succeed in the professional world that they enter, but also flourish in that world and adapt to changes with great facility. Can that challenge be met with current faculty? Absolutely, but it will require different attitudes, skills and knowledge, along with a desire to drive to the leading edge, not only in subject/course content and research, but also clinician and educator performance. The future is ours to create.
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