If you've ever finished a community visit feeling like the textbook doesn't apply, you're definitely not imagining it.

For most of us, our dysphagia training happened through an acute care lens. Hospital placements, stroke-focused clinical education, validated tools designed for inpatients, and a general framework built around short-term, medically urgent care. That training is appropriate for that context. The problem is that we then step into post-acute care territory: individual homes, aged care facilities, disability accommodation, and we try to apply the same principles. And they just don't fit. I'm sure you would have felt this, even if you weren't able to name the problem in the moment.

I've been working as a Speech Pathologist for over 15 years and while the majority of my experience has been in community-based settings in Australia I have also worked in acute, rehabilitation and outpatient clinics in both Australia and the United Kingdom. It wasn't until I started managing a team of SLPs and started seeing adults with intellectual and developmental disabilities in private practice that it really hit me: we've been trying to do acute care in the community. And it's not working.

That realisation is what lead me to develop The 8 Principles of Community-Based Dysphagia Care.

A quick note before we get into it

I want to be upfront about what these principles are and what they aren't.

These are not a research-validated clinical framework. They're a way of organising my thinking, and hopefully yours, about how community-based dysphagia practice is different from acute care, and how we might need to adjust our approach accordingly. They're grounded in the existing literature on community dysphagia practice (there isn't a lot of it, but there is some, and I reference it throughout), my own clinical experience, and conversations with other community-based speechies who've had the same moments of "hang on, this doesn't make sense here."

Using these principles doesn't mean every principle applies to every client, every time. You are the clinician. You know your client. Clinical judgement always comes first. These principles are meant to prompt thinking, not replace it.

With that said, let's get into it.

The 8 Acute Care Assumptions We Need to Unlearn

Before I name the 8 community principles, it helps to name what they're pushing back against. Here are the implicit assumptions most of us graduated with:

1. The purpose of assessment is always to diagnose dysphagia
2. Everyone needs an instrumental assessment
3. If someone is at risk of aspiration, they need a modified diet
4. Modified diets are the first line of defence when it come to treatment
5. It's the responsibility of the speech pathologist to tell clients what they can eat and drink
6. A good assessment always means a standardised test and a complete cranial nerve exam
7. The goal of care is to eliminate all signs of dysphagia
8. Diet and fluid recommendations should be based on VFSS results above all else

In an acute hospital setting? A lot of these make sense. In the community? Most of them don't.

Here's the alternative framework I've built Dysphagia Bites around.

Principle 1: The Clinical Swallow Evaluation IS a Comprehensive Assessment, Not a Screen

In the community, the CSE is often our primary, and sometimes only, assessment tool. But it's not a screen. It's a holistic, context-driven picture of swallowing that includes so much more than a few bolus trials.

A full mealtime observation gives us information we simply can't access any other way: how a client interacts with their family or support workers, how much they're actually eating and drinking, whether fatigue is affecting their intake across the meal, what their mealtime environment looks like in real life, and how important food enjoyment and social participation are to them.

The case history matters enormously here too, perhaps more than in any other setting. In the hospital, dysphagia is often new. In the community, we're often picking up a client who's been living with dysphagia for years. That history: what they've tried, what's worked, how things have changed, is clinical gold.

Howells and colleagues (2019) found that community-based speechies consistently adapted their assessment approach away from acute-style screening and towards this kind of holistic, context-driven evaluation. This is what we need to do in post-acute care. This is good community practice.

Principle 2: Assessment Should Be Highly Individualised

Community referrals don't all look the same. You might be called in to confirm a diagnosis. Or to determine choking risk. Or to develop a mealtime management plan because new support workers have started. Or to provide education to a family carer. Or simply because something has changed and nobody's quite sure what.

The person in front of you won't be a post-stroke inpatient in a hospital bed. They'll be living somewhere: a home, aged care, disability accommodation, supported by people with wildly different levels of knowledge and experience. Their diagnosis could be a stroke, but in the community often caseloads are incredibly diverse so it might equally be cerebral palsy, MND, Down syndrome, dementia, head and neck cancer, or something you've never seen documented in a textbook assessment protocol.

Principle 3: Swallowing Should Be Assessed in Real-World Contexts

Particularly for clients with intellectual or cognitive impairments, a clinic room can give you really unreliable results.

I learned this the hard way. I once assessed a gentleman with Down syndrome in our clinic even though he did not fit criteria for clinic appointments. The referrers insisted this was an urgent case, so I made an exception. His support worker sat there watching him eat and drink in completely atypical ways and said: "I don't know what he's doing there but that is not how he normally eats!" We basically had to start again and rather I used that session predominantly to build rapport and complete a semi-structured interview.

When I later visited him at home, I saw the full picture: eating quickly, hunched over his food, multiple dishes presented at once, watching videos on his phone while he ate, his mum preparing meals in a style I wouldn't have known about from a clinic appointment. That was the real assessment.

Home-based and mealtime assessments using the client's own foods, utensils, and environment give us the most accurate picture of swallowing safety and function. They also reveal practical barriers: meal preparation issues, equipment gaps, positioning problems, carer technique, that would never surface in a clinic room.

Behaviour and environment are also valuable clinical data. It's not just about swallow function.

This means our tools, our communication approach, our documentation, and our management strategies all need to adopt a truly person-centred approach. 

Principle 4: Least Restrictive Interventions Should Be Trialled First

Texture modification should not be our default first response to aspiration risk. And yet, in the community, it often is because that's what we were trained to do.

Before reaching for modified textures and thickened fluids, consider: positioning, pacing strategies, mealtime environment, adaptive equipment, carer training and supervision, and where appropriate, swallowing rehabilitation.

There are a few things worth keeping in mind here. Adherence to modified diet and thickened fluid recommendations in community settings is low. There is no convincing evidence that texture modification or thickened fluids prevent pneumonia. And thickened fluids carry their own risks: dehydration, malnutrition, reduced quality of life, and potentially increased risk of chest infection if aspirated (Werden Abrams et al., 2023; RCSLT, 2024).

It's also worth noting that "least restrictive" isn't a fixed point, it's person-dependent. A chin tuck on every single swallow might feel extremely restrictive to one person, while another genuinely doesn't mind thickened fluids. We need to be asking the person in front of us, not applying a hierarchy of restriction in an abstract sense.

Principle 5: Goals Should Reflect the Realities of Chronic and Lifelong Dysphagia

In acute care, the goal is usually pretty clear: get someone safe, get them eating, get them home. There's generally an expectation of recovery, or at least improvement.

For many of the clients we see in the community: people with progressive neurological conditions, intellectual disability, or palliative care needs, dysphagia is not going to resolve. The trajectory isn't about getting better. It's about living as well as possible.

That means our goals need to look different. Rather than framing success as normalising swallow physiology or eliminating aspiration risk, we need to be asking: Can this person eat in a way that brings them enjoyment? Can they participate in meals with their family or housemates? Are their preferences and dignity being respected? Are the people supporting them confident and well-informed?

Howells and colleagues (2019) found that experienced community-based speechies often consciously reframed what success meant, moving away from biomechanics and towards autonomy, socialisation, and wellbeing. Moloney and Walshe (2019) similarly found that quality of life sat at the centre of community dysphagia management, not as an afterthought, but as the central organising principle.

Principle 6: Carer Involvement Is Essential

In the community, carers are often central to every stage of the process: case history, assessment, implementation, and review.

For clients with intellectual or cognitive impairments, we may be relying on carers to help us understand what we're seeing: what a particular behaviour means, what a typical mealtime looks like, what the person's preferences are when they can't tell us directly. I've made some genuinely embarrassing assumptions before a carer stepped in to clarify. (Tapping their chest doesn't always mean something is stuck. Sometimes it means they want more.)

Carers are often the deciding factor in whether or not our recommendations actually work in the real world. Without their buy-in and capacity, even the best clinical plan will fall over. Howells and colleagues (2019) identified carer involvement as essential to adherence and sustainability in community dysphagia management.

And carer education needs to be tailored to their role, their existing knowledge, and the specific context. The way you train a family member at home is different from how you train a nurse in residential aged care, which is different again from how you train a support worker in specialist disability accommodation.

Principle 7: Shared Decision-Making Should Guide Dysphagia Care

In acute settings, decision-making is often rapid and protocol-driven. There's a level of medical urgency that means there's limited room for lengthy discussion, and many patients are in a position where they're looking to clinicians to guide them.

Community dysphagia care is different. It's long-term. It's lived. And clients who've been managing dysphagia for years often know their own swallowing far better than we do. They're not novices in the situation they become the expert.

Shared decision-making in this context means genuinely integrating clinical evidence with the person's values, goals, and circumstances. It means our recommendations need to be sustainable and acceptable, not just technically sound. And it means moving away from a purely medical model of care towards something more aligned with a social disability model.

Recommendations that don't fit a person's life are unlikely be followed, and we need to keep that in mind.

Principle 8: Diet and Fluid Recommendations Should Not Be Based on VFSS Results Alone

VFSS and FEES give us valuable biomechanical information about swallowing physiology. But they don't capture how someone actually lives and eats.

My view, and I appreciate this is not universally held, is that the speech pathologist doing the fluoro is an expert in that procedure and its interpretation. The community speech pathologist is the expert in their client and their clients' individual situation. Both roles matter. But when it comes to making diet and fluid recommendations for someone living in the community, I think the community clinician is better placed to make holistic recommendations.

Those recommendations need to account for far more than aspiration status: the client's chest history, oral health, mobility, nutrition and hydration, carer capacity, meal preparation realities, the client's own preferences and goals, and what they've been safely eating and drinking for the past two years.

I think of it a bit like a GP referring a patient for radiology. They want the radiologist's expertise in the results. They don't want the radiologist,  who has never met this patient, writing the management plan.

Why I Created These Principles

These 8 principles are the foundation of everything I do at Dysphagia Bites. They're why I started the @dysphagiacommunity Instagram account, why I created the Dysphagia Research Bites Podcast, and why I built the on-demand courses and in-person workshops.

Because I genuinely believe there is a gap between how we're trained and what community practice actually demands. And because of that gap, community speechies are often left feeling like they're doing something wrong, when really, they just haven't been given the tools they need for this specific context.

These principles are my attempt to name what's different.

Free Resources

📄 Free PDF Summary of the 8 Principles: a two-page reference you can save and come back to

🎧 Podcast Episode 10 of Dysphagia Research Bites: The 8 Principles of Community-Based Dysphagia Care: I walk through all 8 principles with some more detail about how they came about and little added personal story in there ;)

References

Howells SR, Cornwell PL, Ward EC, Kuipers P. Dysphagia care for adults in the community setting commands a different approach: perspectives of speech-language therapists. Int J Lang Commun Disord. 2019 Nov;54(6):971-981. doi: 10.1111/1460-6984.12499. Epub 2019 Sep 3. PMID: 31479197.

Howells SR, Cornwell PL, Ward EC, Kuipers P. Understanding Dysphagia Care in the Community Setting. Dysphagia. 2019 Oct;34(5):681-691. doi: 10.1007/s00455-018-09971-8. Epub 2019 Jan 7. PMID: 30617843.

Moloney J, Walshe M. Managing and supporting quality-of-life issues in dysphagia: A survey of clinical practice patterns and perspectives in the UK, Ireland and South Africa. Int J Lang Commun Disord. 2019 Jan;54(1):41-49. doi: 10.1111/1460-6984.12429. Epub 2018 Oct 26. PMID: 30362200.

Royal College of Speech and Language Therapists. (2024). Position paper on the use of thickened fluids in the management of people with swallowing difficulties. RCSLT Position Paper 2024. London: RCSLT.

Werden Abrams S, Gandhi P, Namasivayam-MacDonald A. The Adverse Effects and Events of Thickened Liquid Use in Adults: A Systematic Review. Am J Speech Lang Pathol. 2023 Sep 11;32(5):2331-2350. doi: 10.1044/2023_AJSLP-22-00380. Epub 2023 Jul 12. PMID: 37437527.