But When Do I Discharge? An SLP’s Guide to Progress and Plateau

It’s interesting, seeing patients over the course of progressive sessions. When you are in graduate school, you are so worried about content and making sure you can remember every fact, that you are likely not giving much thought to a normal and usual pattern of sessions for a patient. You may not have a good idea of “how long is too long to keep a client on caseload?”

Fast-forward to your awesome new job, but after the newness wears off, you are stuck with seemingly unattainable productivity goals, or IEP’s goals that just will absolutely never end. You may feel pressure to qualify a student or patient for therapy.

You have your cookie-cutter patients who get a good grasp on what the rehabilitation process entails. During my voice rehabilitation sessions, these folks understand what I’m asking in the first session, and are generalized and out my door with a completely improved quality of life by session 5. Others, trudge along through 3 sessions or so and then suddenly flip the pancake over, figure it out, and are also done by session 5. The challenge, especially for these long term goals, are your patients who are 7-8 sessions in and are having struggles. This may be the time to refer back to the ENT, or perhaps to a different care provider to see if it may be a personality connection issue.

Children with speech or language disorders are different, and may require a much more long-term plan of care with growth of language and age paired with intervention from you, the qualified SLP. For the medical SLP, you may be struggling with cognitive patients who just can’t remember the swallow recommendations you gave them yesterday, let alone what day it is. Dysphagia rehabilitation may take 4-6 weeks of work with good progress as determined by MBS or FEES, and there still may be attainable improvement after that.

So, when has progress stopped? How do you know?

If you feel like you’re continuing the same session over and over, with no measurable improvements, and you have tried many different treatment options and angles, it may be time to discharge. This is why measurable goals are important, as well as input from the patient. With children, it’s harder to see this because many times they meet you with resistance, but you know you’re still making a difference. With adults, if they feel they’re not making progress, they’ll usually either not show up or make you get out of their hospital room. Others want to stay in your office once per week forever it seems like, even if they are inching along with technique improvement.

My advice? Keep the end goal in sight. If your patient is continuing to make gains, even small, you are likely improving quality of life. But, don’t be too proud to refer if you feel like you’ve hit a brick wall or to discharge if you feel you’ve done all you can do. There are times when I know I’ve tried everything, and I just have to throw my hands up and inform the patient that I’ve done all I can.

No one likes to admit defeat, but we must always be aware of levels of progress and when our services are no longer medically necessary.


Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.


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