Navigating the Virginia and North Carolina Systems: Access to Dysphagia Services Across States

As a private practice SLP owner serving families in both Virginia and North Carolina, one of the most common questions I hear is: "We're moving across the state line. Can we keep working with you?" The answer is rarely a simple yes or no. Dysphagia care is deeply personal, often medically complex, and interruptions in service can have real consequences - from aspiration risk to nutritional decline. Whether you're a clinician planning cross-state care or a family navigating a move, understanding how these two states handle SLP services is essential.

This article breaks down the key considerations for maintaining continuity of dysphagia care between (my two home states) Virginia and North Carolina.

Licensure: The Non-Negotiable Starting Point

In the United States, speech-language pathology services are regulated at the state level. That means an SLP licensed in Virginia cannot simply begin treating a patient who has moved to North Carolina, or vice versa, without holding an active license in the state where the patient is physically located at the time of service. This rule applies to both in-person and telepractice sessions.

Virginia licenses SLPs through the Board of Audiology and Speech-Language Pathology, while North Carolina operates under the Board of Examiners for Speech-Language Pathologists and Audiologists. Each board has its own application process, fees, continuing education requirements, and timelines. If you're a clinician planning to serve patients in both states, you'll need to apply for and maintain dual licensure.

One promising development in increasing dysphagia access across states, is the Audiology and Speech-Language Pathology Interstate Compact (ASLP-IC). This compact, championed by ASHA, is designed to create a streamlined pathway for SLPs to practice across member states without obtaining a full separate license in each one. Both clinicians and families should check the current compact membership status for Virginia and North Carolina, as state participation is evolving. Even with a compact in place, clinicians must still comply with each state's practice act and scope of practice regulations.

Scope of Practice: Similar but Not Identical

Both Virginia and North Carolina recognize dysphagia evaluation and treatment as within the SLP scope of practice, consistent with ASHA's national position. However, the details matter. State practice acts may differ on questions like whether an SLP can independently order instrumental swallow studies (such as a modified barium swallow or FEES), or whether a physician referral or prescription is required.

In practice, clinicians should review each state's practice act carefully and confirm whether specific procedures, particularly instrumental assessments, require physician oversight or a collaborative agreement. Families should know that a change in state may mean a change in how quickly they can access certain evaluations, depending on local referral requirements.

Telepractice: A Bridge Across State Lines

Telepractice has become a powerful tool for dysphagia management. Research shows that the diagnostic accuracy of virtual clinical swallowing evaluations is comparable to in-person assessments for patients whose dysphagia is not severe. Swallowing therapy can also be conducted remotely, with some evidence suggesting better therapy adherence when telehealth is used. Patients can even self-administer validated screening tools like the Yale Swallow Protocol under remote guidance to identify aspiration risk.

For families moving between Virginia and North Carolina, telepractice can provide critical continuity, but only if the clinician is properly licensed. The golden rule of telepractice is that the clinician must hold a license in the state where the patient is located during the session. A Virginia-licensed SLP cannot provide a telepractice session to a patient sitting in their new home in North Carolina without also holding a North Carolina license.

Both states have their own telepractice regulations, and clinicians should verify whether any additional telepractice-specific registrations or notifications are required by the licensing board. ASHA's telepractice resources and each state board's website are the best starting points for current requirements.

Interstate Telepractice Ethics and Consent

Ethical telepractice across state lines demands more than just checking a licensure box. Informed consent for telepractice should be obtained in writing and should clearly explain that services are being delivered remotely, outline the technology being used, address privacy and data security, describe the limitations of virtual assessment (particularly for severe dysphagia where hands-on evaluation is often critical), and identify what to do in an emergency.

Clinicians should also ensure that all individuals present during a session, at both the clinician's and the patient's location, are identified and disclosed before the session begins. This is especially important in dysphagia telepractice, where a caregiver or family member may need to assist with food and liquid trials during a virtual swallowing evaluation or treatment session.

The ethical principles of autonomy, beneficence, nonmaleficence, and justice all apply with added complexity in telehealth. Clinicians must use professional judgment to determine whether a particular patient is an appropriate candidate for virtual dysphagia services. Patients with severe cognitive impairment, those who lack a reliable caregiver to assist during sessions, or those with severe dysphagia requiring hands-on assessment may not be well served by telepractice alone.

Documentation and Authorization for Cross-State Care

When a patient transitions between states, thorough documentation is the clinician's best friend. A comprehensive transfer-of-care packet should include current swallowing evaluation results (clinical and instrumental), diet recommendations with the International Dysphagia Diet Standardisation Initiative (IDDSI) framework levels, a summary of therapy goals and progress, any physician orders or referrals, and insurance authorization details.

Insurance is another layer of complexity. Medicaid coverage varies significantly between Virginia and North Carolina - different covered services, different authorization processes, and different reimbursement rates. Private insurance plans may also have state-specific network restrictions. Families should contact their insurance provider before a move to understand how coverage will change and whether prior authorizations need to be re-obtained in the new state.

For clinicians, maintaining clear documentation of medical necessity is essential regardless of the state. Both states require that dysphagia services be supported by evidence of functional impairment and a treatment plan with measurable goals.

Resources for Caregivers When Local Services Are Limited

Not every community in Virginia or North Carolina has easy access to a dysphagia specialist. Rural areas in both states can face significant shortages of SLPs with swallowing expertise. When local services are limited, families and caregivers have several options to explore.

First, telepractice can fill gaps. A growing body of evidence supports remote dysphagia therapy, and many private practices now offer virtual sessions across both states (with appropriate licensure). Second, ASHA's ProFind directory can help families locate SLPs with dysphagia specialization in their area. Third, university speech-language-hearing clinics, such as those at James Madison University, East Carolina University, UNC-Greensboro, or Old Dominion University, often provide dysphagia services at reduced cost and can be excellent resources.

Caregivers can also be empowered with education on safe swallowing strategies. Simple techniques, like ensuring upright positioning during meals, modifying food textures, encouraging slow and mindful eating, and learning compensatory maneuvers such as the effortful swallow, can reduce aspiration risk while families wait for or transition between services. Your SLP should provide written home programs and caregiver training as part of any dysphagia treatment plan.

Finally, organizations like the Dysphagia Research Society and the National Foundation of Swallowing Disorders offer educational materials and support networks for both clinicians and families.

The Bottom Line

Moving between Virginia and North Carolina doesn't have to mean a gap in dysphagia care. But it does require planning! Clinicians should proactively pursue dual licensure or compact privileges, stay current on each state's telepractice rules, and build robust transfer-of-care documentation. Families should start the conversation early, ask their current SLP for a detailed care summary, and reach out to providers in their new state before the move.

Dysphagia care is too important to leave to chance. With the right preparation, continuity of care across state lines is absolutely achievable.