Understanding and Managing The Growing SLP Shortage

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A Forum for School Leaders

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UNDERSTANDING AND MANAGING THE GROWING SLP SHORTAGE

By Karen Roth, M.S. CCC-SLP, Clinical Professor, Arizona State University
THE SIZE AND SHAPE OF THE SLP SHORTAGE

For many of you it may seem like qualified SLPs are disappearing, and no wonder, because the SLP shortage is affecting every school and every school administrator to some degree or another. Luann Purcell, executive director of CASE, (Council of Administrators of Special Education) offered her perspective on the shortage at the 2012 CASE national conference. The shortage of speech and language pathologists is very real and persistent, she said. There are some systemic issues that prevent us from having adequate supply of SLPs. As Luann says, we know that the SLP shortage is an ongoing and growing problem. And, there is data to suggest its not going away. Forecasts from the U.S. Department of Labor as well as numbers included in a recent U.S. News and World Report article about the hottest jobs of the future show continued growth in demand for SLPs, well above that of the national average for other professions. So, we can expect to have significant growth in job openings for SLPs. This is not a short-term problem; this is very much a long-term problem that is going to require some long-term solutions. SLPs face many challenges. All SLPs have significant education requirements due to scope of practice, clinical training needs, and the limited capacity of graduate programs. Schoolbased speech language pathologists have special challenges that include high caseloads, shifting expectations and increased complexity in student needs. The first major challenge for speech language pathologists is training. I get questions from friends, colleagues and people in the community about why SLPs go to school for so long and why we have to jump through so many hoops in order to become Certified. I dont think the community at large, or even professionals with whom SLPs work understand why the job requires so much training. One reason for such extensive training is the scope of practice. SLPs must demonstrate competency in providing services for all communication disorders in populations from birth to death. They not only have to be able to serve those in need across the entire lifespan, but also across all communication disorders. What I mean is swallowing disorders, feeding disorders, voice and other complex disorders that require a lot of education and training. In addition to the lifespan and the broad scope of practice, to be licensed and certified, there are multiple environments in which speech language pathologists have to be trained in order to effectively deliver services.
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SLP training requires classroom-based academic training as well as 400 clinical clock hours. Clinical hours are much more difficult to come by and are more intense than classroom-based education. The training has to be supervised by speech language pathologists who have what we call their Cs -- their Certificate of Clinical Competency--- which fully certifies them to bill for Medicaid services and allows them to work without supervision. The CCC credential is reached after nine to twelve months of full-time supervised employment after the masters degree is earned. Beyond the two-year masters degree, a year of clinical fellowship is required before a speech language pathologist has her Cs. The intensity of that clinical training requires one-on-one mentoring across a variety of settings. If you add it all up -- the clock hours, supervision by someone with their Cs, the intensity of the training in hospitals, school settings and outpatient clinics -- you can see how difficult it is to train enough SLPs to meet the growing demand. The capacity of graduate training programs is a significant factor as well. Most programs accept only 15 to 20 graduate students a year, and the number of applicants far exceeds the available space. Online courses are expanding, but the necessary clinical training clock hours and competencies cant be done via online courses. What may worsen the training picture is what many see in the future. We anticipate that a clinical doctorate may eventually become the entry-level credential for speech language pathologists. Now, its a masters degree, which used to be commensurate with our colleagues in physical therapy and occupational therapy. PT and OT have gone almost exclusively to a clinical doctorate. If we are looking at the SLP profession also moving in that direction, it means more extensive training which will do nothing to address the shortage of SLPs. According to ASHA statistics, since 2009, the average number of applicants to SLP graduate programs was 142.5, and the number of admissions was less than half that. Enrollment is far smaller than admission, partly because only a percentage of those who are accepted actually enroll. Some applicants are admitted in several places and obviously accept admission to only one program. So enrollment is significantly below admission and the number of degrees awarded is even lower than that. So out of over 142 applicants, only 24 speech language pathologists graduate and go out into the world. You can see that that is a significant aspect to this problem. With regard to the school speech language pathologist perspective of the challenges that contribute to the shortage, what we see in the ASHA (American Speech and Hearing Association) school survey is that workloads and caseloads continue to increase. Most speech language pathologists say there isnt a shift from the caseload approach to a workload approach in order to better manage more complex students. In other words, speech language pathologists typically manage a certain number of students on their caseload regardless of the complexity and severity of the disorders. Many school districts are working hard to make sure that there is balance. But, most speech language pathologists who work in schools across this country say that the workload isnt a factor in mitigating the size of their caseload. Currently the mean number of students on a caseload is in excess of 40 students for a speech language pathologist.
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In that same ASHA school survey, speech language pathologists cited some of their other challenges. One of those is the high amount of paper work. We all know this is a federal requirement that we cant do that much about. SLPs who responded to the survey indicated that large caseload is a big factor in why they leave the school setting. SLPs are also challenged by the limited understanding of their role by families, teachers and administrators and also by students who are receiving services. Another frustration is the lack of time for appropriate service delivery. SLPs are expected to provide services that are effective, but they dont have enough time to manage their caseload in a way that allows them to provide services in the most efficacious way. Lack of time for planning, for meeting and collaborating with fellow staff is also a frustration I hear from teachers and speech language pathologists. In a school setting, we need time for planning, meeting and collaborating, and there just isnt time to do it in the way that caseloads and services are currently managed. These are some of the challenges SLPs are citing as reasons why they quit their jobs. But, like most educators, SLPs are dealing with changing and expanding roles and expectations. Speech language pathologists report feeling a lack of specificity for their role as the nationwide school service delivery model changes. Response to Intervention is one area of concern. Over a quarter of speech language pathologists indicate they have no role in Response to Intervention -- that they dont participate in RTI on any level, which sounds shocking to me. In addition, many school districts are looking at the role of every school professional in educating the child and the outcomes of the childs education. They are using some new tools, including Value Added Assessments. When ASHA reviewed the value added assessment tools, they found that they really didnt apply to speech language pathologists and take into account their unique role in a school district. ASHA has developed a way of assessing the SLPs contribution to the outcomes of student education through something called PACE (performance Assessment of Contributions and Effectiveness of Speech-Language Pathologists). You can learn more about this on the ASHA website. We know that Common Core Standards are coming into play nationwide as well. Common Core is shifting how speech language pathologists are writing short-term goals, how we are writing IEPs, how we are targeting the relevant skills in regards to communication and cognitive linguistic skills and evaluating these important components as they relate to these Common Core Standards. Whats more, SLPs are required as practicing professionals to use evidence-based practice, much the same way as physicians are required to use evidence-based medicine. In fact, our model for using evidence-based practices comes straight from the medical model and it is to be equally applied in school districts. Yet, I hear from so many speech language pathologists that they simply dont have the time to do literature reviews and study the research and apply it clinically to their own practice in a school-based setting.
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Finally, it seems that the challenge in schools also has to do with the complexity of students we are serving. This has increased very significantly. The students that SLPs and teachers are serving in their classroom are far more medically fragile than weve seen in the past. We have premature infants surviving at 26 weeks of gestation because of medical technology. The aftermath of that increased survival rate is that many of these children arrive in our school districts with huge needs. Their communication needs can be impacted by the fact that they have a tracheostomy. They may have a ventilator that helps them breathe, they may have had a feeding tube placed permanently. All these things impact their participation as a student in the classroom, and it impacts the type of services they can receive. The survival rate of premature infants is just one reason why the scope of practice for the SLP has increased and why there is much more demand for expertise in a school district. There is also greater need than ever before for augmentative communication, autism specialties, feeding specialties, and reading specialties, because reading is language. All of these things fall within our scope of practice. The students on our caseloads have very complex situations. Some of them are in and out of the hospital, and there are very few people in the school districts that are better trained than a speech language pathologist to understand the needs of the complex and medically fragile students who are arriving. With all these factors contributing to the SLP shortage, what are universities doing to increase the flow of qualified SLPs? There are a lot of programs being put into place. At Arizona State University, for example, we have a part-time employment program for speech language technicians working in the school districts. If they meet the admission requirements for our Masters program, we give them an opportunity to do the two years of work across three years while they continue to work in their employing school district. Classes are scheduled in late afternoon and evening to accommodate their schedule. There are programs like this across the nation, as well as some online programs that either require once a year onsite participation or is all online and students have to find some clinical placements within their community. In addition, ASU, many community colleges and four-year universities have started providing training for SLP-As, Speech Language Pathology Assistants.
STRATEGIES FOR RECRUITING SLPS TO WORK IN SCHOOLS

Weve seen that there are a number of challenges SLPs face, starting with getting into graduate school, and then on the job as well. But as CASE director Luann Purcell mentioned, the reason for the SLP shortage is systemic. Finding a solution is not just about addressing retention. Our recruiting practices are also fueling the SLP shortage. I asked a recent SLP graduate to offer her perspective about the recruiting process from a recent personal experience, and to offer some ideas you can use to improve your odds of finding the SLPs you need to work in your schools.
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First, realize that SLPs want to work in schools. And by and large, they do. This is something that we have been aware of at ASU. SLPs who come through our program want to get a job in a school district. They are interested in serving that population. Its an opportunity to work in an environment where they dont have to bill insurance and where they get to serve students who have special needs. SLPs get to see students in their environment in the culture of their school that uses the language of the curriculum. To have the opportunity to provide services in schools is really ideal for a SLP. So, we know that almost half of all SLPs work in schools and the rest of SLPs are distributed through other settings in smaller percentages. At some point in their career, the majority of SLPs work for a school district. In terms of the ASHA school survey, we made note of the increased caseloads and workloads that have a negative impact on the SLP shortage. Decreased appropriate service delivery and quality of services were the perceptions of SLPs, and ultimately those things add up to a decreased job satisfaction. The numbers speak loudly that SLPs want to work in schools, but we know some of the struggles for SLPs in that setting. Id like to share the viewpoint of Jennifer, a recent SLP graduate from the ASU masters degree program and now works for a school district. I had the opportunity to have a conversation with her and she gave me some insight about things that attracted her to school district where she works now and things that were impacting her decision. Jennifer was hired in August by a school district and placed in two environments. She works in a preschool, where it is an inclusion preschool, and on top of that she has some resource students she works with in the resource room. She works in the preschool two days a week and in an elementary school another two days a week. Jennifer is responsible for 44 IEPs: just over 30 elementary students and in the preschool, 11 in inclusion and three resource kids. She doesnt have any help. Jennifer only interviewed for SLP positions with school districts. She was a teacher in her previous career, and a school setting is where she is comfortable working. She interviewed with four different districts and ultimately narrowed the choice to two districts. The position she accepted was with a district that puts a cap on caseload. The caseload cap was the deciding factor for Jennifer, but there were other reasons that swayed her decision between the two finalist districts during the recruiting process. For the school district that she didnt choose, she was impressed by the people with whom she interviewed. They were very excited, outgoing and welcoming. Jennifer almost accepted the position there due to the interesting personalities. The school district that she chose wasnt quite as welcoming, but when she told them she might go work for another district, they pulled out their guns and told her that they really wanted her, and offered to make her position easier.
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How did they make it easier for her? Jennifer completed her degree on a scholarship and with a loan. The scholarship required that she work with preschoolers. The loan had a provision for pay back based on work with Title I schools. The school district she chose put her in a situation where she could have her scholarship and loans requirements fulfilled. Those elements certainly would make her life easier. The districts she eliminated during the recruiting process werent as outgoing, they didnt seem to take a real interest in Jennifer and they didnt have a cap on the caseload. Now that Jennifer is on the job, does she feel like the school district she works for understands her skills and her education and what she can bring to the table in terms of providing services as a SLP? When she walked into the classrooms in elementary and the preschool, she wasnt provided with the materials she needed. She says she has been put in a situation where the school district has been having trouble retaining SLPs because there isnt a good understanding of the SLP role in the classroom were and the resources needed. Jennifer sees a big issue with retention in school districts. District leaders are putting new SLPs into positions where other district SLP have not wanted to be, and there is a reason why they havent wanted to be there. There is a reason why SLPs are having difficulty doing their job; there is a level of frustration. Jennifer can see why someone would want to quit and go to a private practice setting where his or her job is easily understood. This new SLP graduate thinks recruiters should understand that during the first year on the job new SLPs need to be nurtured. They are still in a level of learning and they need an environment that is supportive of them. Jennifer doesnt talk about money being a factor in her decision. We know that districts have a certain amount of money to work with, and there is little that can be done about it. But, the things that were important to Jennifer in making her decision were about capping caseload, meeting the other SLPs and having some support and understanding of the role of an SLP. Some of the other things we heard from other SLPs who were new to working in schools is that they were offered jobs without an interview. This sends a negative messagethat the position is not worth having. It looks like a desperate situation, and that can scare off a new grad. When graduates see a lot of positions being filled with less than highly qualified staff, when those holes are plugged with people who dont have the background education and knowledge to provide adequate services, it also sends a negative message about the value of SLPs in that district. Overwhelming new SLPs with too many responsibilities can also be a factor that impacts your recruiting efforts. One way to make the work environment more attractive is to hire SLP assistants. ASHA now has great resources on their website about the appropriate use, scope of practice and supervision of SLP assistants. These assistants are not aides, someone who doesnt necessarily have any special training or certification or licensure requirement, whereas a SLP assistant is a trained person who is licensed. There are, across the country, two-year programs at community colleges offering certification as a SLP assistant.
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There are clinical hours that are supervised and required with those programs. Many states have licensure for SLP assistants. I currently teach Treatment Implementation for SLP assistants at ASU, so our students coming out with a bachelors degree have the option to also take additional certification courses and receive clinical clock hours. Many of them are getting their clock hours in school districts where they want to continue to work. So there are a lot of things in place to begin to certify assistants because there is a role for them and they are needed.
SOLUTIONS TO THE SLP SHORTAGE

We know that many school districts can improve their recruiting and retention methods. But as CASE Executive Director Luann Purcell reminds us, the SLP shortage is systemic and therefore, there is no single solution. Unfortunately, there isnt a magic wand that can fix it. We really need a multi-faceted approach. We need to address this problem from a number of directions because there is a growing need for speech language pathologists and the shortage could become more of a concern given that degree requirements may shift to a clinical doctorate in our profession. We are going to have to shift our thinking about speech language pathologists in school districts. We need to recognize their unique roles and the services that they can provide and start to use them as they should be used. The first solution is the SLP Assistant, and the key here is to supplement SLP services with them, not substitute SLP services. The problem in the past has been non-certified bachelors-level SLPs who may be great at ground-level therapy implementation, have been used in place of a SLP, instead of to supplement a SLP. This creates a myriad of problems. What we would like to see are well-trained, licensed appropriate professionals coming in as SLP Assistants (SLP-A). These are people who are able to implement treatment supervised by a Certified SLP. The supervision requirements are very well delineated by ASHA. One SLP who has had the Cs for over a year --which means two years after graduation --- for every two SLP-As and/or they can supervise three part-time SLP-As. We would also like to see that SLP-As are practicing within their scope of practice as directed by ASHA, that they arent providing services to more medically complex kids and they are not doing assessments. SLPs can supervise SLP-As in providing some of the treatment to students so that the SLP can participate in the more complex, more dynamic aspects of assessment, and have more time to work on early treatment and play a much-needed role in Response to Intervention. Appropriate use of an SLP-A meets student needs while allowing SLPs to use the full scope of their SLP Masters degree, and to be able to direct the assistants to provide quality evidence-based practice. Many of the solutions for service provision include using the SLPs expertise better. If you access the PACE version of the value-added assessment developed by ASHA it will help you define for yourself what your expectation can be of really using your SLPs in the most efficient and effective way.
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We can use SLPs in consultative models, especially in regards to Response to Intervention, to be able to do things more intensively at a beginning level. Years ago it used to be the student really had to fail before we could anything. Now, with multiple tiers of RTI it allows us to do something earlier on. Our SLPs need to be utilized in these areas so that these students dont continue to fail and end up on SLP caseloads and staying there indefinitely. In addition, it is attractive for new SLPs coming onboard to ensure that their workload is valued. If they have classrooms with a lot of kids who have complex needs, be sure that those students count for more of a workload than the students with fewer needs. Another part of the solution is telepractice. Online delivery can especially help some rural school districts having difficulty finding SLPs and managing workload. They can really maximize a SLPs time by limiting the driving time. When you have needs across multiple schools and you are putting an SLP in a car, it is taking time out of their day that would be better used for service provision. In addition seasoned SLPs who would otherwise have to leave the work force can have a more flexible schedule and work from home. SLPs with specialized expertise can be brought into the team and matched more specifically to the students needs, such as bilingual students or students with voice or fluency disorders. Telepractice also allows schools some scheduling flexibility. Online SLPs can serve students before and after school, homebound students, students transitioning from a hospital back into school, summer provision of services, and covering vacations of staff SLPs. Really, through telepractice you can provide these services and do it across time zones. Online speech and language services can also be combined with on the ground SLPs to balance caseload and workload. A number of districts across the country combine the of services of an online SLP with services delivered with an SLP on the ground. So for instance, the SLP at the school location may do the assessments, while the SLP who working in an online environment is providing the intervention. In addition we also know that not all students are candidates for telepractice, so some students can be served with an online intervention program and others would work with your on the ground SLP. Further, online SLPs are increasingly being used to provide service to small groups of students. In fact, they sometimes work with students in multiple locations who attend the same school, and they might also have one student from one school, another student from another school, and the SLP in a third location. So there are a lot of different ways that you can balance a group. The online SLP is accountable in the same way as your traditional SLPs to manage progress, to manage IEPs, and to do the reporting in terms of working and developing the IEPs. Online speech therapy is really just an alternate service delivery model. You really need to think about ways to make your school more attractive to SLPs. I think it is very important for SLPs to be valued for what they bring to the table professionally It is important to recognize that SLPs arent speech teachers, it is an important distinction. Teachers bring an amazing set of skills to their classrooms and to doing what they do and should be valued for that. SLPs bring a different set of skills and should be valued for these
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specialized skills. In addition, having SLPs at a district, leadership level is really important. We need input at the district level keeping on track with SLP use and meaningful and efficacious service delivery. Contract companies are in option as well. They are costly, but they provide certified SLPs. Contract companies go to great lengths to make sure that their employees are licensed and certified and have completed background checks. So a fully certified SLP can be utilized via a contract company versus a highly qualified directly-highered staff member. Small but creative support methods are important too: Being willing to give a caseload cap, being willing to assign a new SLP to a school that is serving lower socioeconomic students so that her student loans could be forgiven to a certain degree. These types of small, but creative support systems are some of the most important things district administrators can do to make the job attractive to SLPs. Above all, recognizing that speech-language pathologists have this unique and diverse skill set that covers a broad range of cognitive-linguistic difficulties is very important. I have another suggestion from Luann Purcell. She advocates for alternative models, that we think about other ways to use our SLPs. So for example, Luann suggests that we schedule SLPs in our classrooms, which of course will help teachers learn how to work with our kids, and integrate new classroom strategies, including the idea of online speech therapy. We hear a lot of questions from district administrators about other approaches to providing services with staff that may not have a masters-degree. For example, you may have special education staff that have only a bachelors degree, and may not have the GPA required to be admitted to a graduate program. These individuals may do an amazing job in your schools with the children, and I know you would love to see them get accepted into a masters program.. Now for these individuals, if they are being utilized where they have their strengths, it is wonderful if we can supervise them so that they can continue to provide services. If they do get admitted into a masters program, they will have to learn to provide services beyond what they do with your students. With the SLP license and certification they will need to learn to work in an ICU and see ventilator patients who have swallowing disorders and need speaking valves for their trachs. So they have to be able to perform in a graduate program. Front-line treatment implementation isnt the same as planning and providing services across the scope of practice and the lifespan. One skill does not necessarily translate to the other.
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For those who are compatible with a masters program, there are online courses that can help them take transferrable credits that could raise their GPA and make them more competitive. Whats more, if they take some online classes, graduate programs are more willing to look at classes that are related to the profession than they are for, say, an undergraduate history class. So the GPA for SLP classes is going to be far more relevant for that person. If they take those classes, raise their GPA, take the GRE, and get recommendation letters, they could potentially enter one of the part-time employment programs that let them work while completing requirements for a masters. If they are not able to do that, we really need to maximize the skill set that they are showing you and supervise them and allow them to do a great job as a SLP Assistant. When you have an assistant, regardless of their degree level, you are going to differentiate between skill sets. It is important to supervise more heavily when they start working in your district. Assess what they are capable of doing, provide a lot of modeling, provide support and detail about the type of implementation you expect from them. You may ease into their caseload by starting with one type of student, and add on a little bit more as you determine the best fit. So, although a student with a bachelors degree is going to have a far deeper understanding about communication disorders, the clinical clock hours are going to typically be the same for both 2-year and 4-year programs to get the SLP-A certificate.
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About The Author Karen Roth, M.S., CCC-SLP

Karen Roth, M.S., CCC-SLP, Clinical Associate Professor at Arizona State University, has worked as a SLP in school districts across three states and has presented nationally on topics related to the SLP shortage including presentations on creative scheduling and collaborative IEP writing. She recently coordinated a workshop for Arizona school-based SLPs regarding the use of SLP-Assistants as a way to address increasing workload demands while preserving the quality of services to students.
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About SPED Ahead

SPED Ahead is an opportunity for school administrators and special education specialists to catalyze discussions about new ideas and promising practices that help exceptional students achieve. With a series of free interactive online events and related multimedia webbased resources, we will explore answers to tough questions and shape effective leadership strategies for addressing special needs students challenges for literacy skills, scholastic achievement and peer relationships.
About PresenceLearning
At PresenceLearning, we love to see children thrive, which is why we are making the promise of live online speech therapy (sometimes called telepractice) come true. With the ongoing shortage of SLPs (speech language pathologists) and budget pressures in school districts reaching crisis proportions, innovative modes of delivery have become essential for giving children the speech therapy services they need. A large and growing body of research, starting with a seminal study by the Mayo Clinic in 1997, demonstrates that live online speech therapy is just as effective as face-to-face therapy. Our mission is to make live online speech therapy practical, affordable and convenient while providing an extraordinary therapy experience for each child. The PresenceLearning solution includes: access to our large and growing network of top-notch SLPs the latest video-conferencing technology the most engaging games and evidence-based activities time-saving collaboration and practice management tools targeting SLPs and educators Join the growing group of SLPs, educators and parents committed to seeing children thrive as part of the online speech therapy revolution.
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new realities

A Forum for School Leaders