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This section contains examples
of reports prepared by members of the Medicare Implementation
Team. Their purpose is to assist SLPs in the development
of reports that closely follow the Medicare protocol and
address all the requirements set forth in the RMRP. For
a copy of the protocol, go to www.aac-rerc.com. Additional
examples will be posted from time to time and existing reports
may be modified as we learn more about the process. Our
intent is to provide a range of examples that represent
different types of individuals with disabilities that benefit
from AAC technology.
Medicare suppliers are required to keep
these reports for 7 years in case of an audit. The SLP report
forms the basis of the decision to fund an AAC device.
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1. Example of individual
with TBI
Facility Name
Department of Speech-Language Pathology
Facility Address and Phone Numbers
MEDICARE FUNDING
REQUEST
FOR SPEECH GENERATING DEVICE (SGD)
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I. DEMOGRAPHIC INFORMATION
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Patient's
Name:John Doe
Date of Birth: 0/00/00
Address: |
Social
Security #:
Phone Numbers: |
|
Patient's Primary Contact
Person:
Address:
|
Relationship to Patient:
Phone Numbers:
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| Medical
Diagnosis: Traumatic Brain Injury due to motor vehicle
accident |
Date
of Onset: 2-25-87
Date of Evaluation: |
Date of Request: |
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Physician:
Speech-Language Pathologist:
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Phone Number:
Phone Number:
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II. CURRENT COMMUNICATION IMPAIRMENT
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A. General Statements
Impairment Type & Severity
(ICD-9 Diagnostic Code: 784.5)
Patient presents with a profound dysarthria and
apraxia. Has left facial weakness. Oral motor control
limited to gross movements only (e.g. slight opening
& close of right side of mouth). Patient is
unable to phonate on command. Unable to elicit phonation
during automatic speech tasks (e.g. sigh, laugh).
Anticipated Course of Impairment
Patient is > 10 years post-injury. Dysarthria
and apraxia are judged to be stable and chronic.
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B. Comprehensive Assessment
Hearing
No problems with hearing noted or reported. Discriminated
sentences on SGD with synthetic speech with 100%
accuracy.
Vision
Patient is legally blind. Reports seeing light,
some colors, and forms. The patient cannot rely
on vision to access an SGD, but can use Morse code
or auditory input.
Physical
Functional Status: Patient is wheelchair dependent,
quadraplegic, legally blind, fully assisted for
self-care. Receives all nutrition through gastrostomy
tube.
Seating and Mobility: Patient
has Quickie P190 power wheelchair with joystick
located for attendant control. Sits comfortably
for extended time periods. No problems reported
or noted. Patient has manual chair. Will return
to Seating Center for proper fitting. Needs access
to communication system from both chairs.
Motor Control: Limited
to approximately 1/4 to 1/2 active range of motion
right elbow and shoulder for internal and external
rotation. Functionally, patient can access area
of approximately 8" wide X 5" deep when
target centered on his lap. Is able to extend fingers
of right hand in patterned movements, can isolate
thumb to move anteriorly and posteriorly along the
surface of his index finger.
Access to Devices: Dual switch Morse code
input.
Language Skills
Language falls within functional limits. The patient
answers personal yes/no questions with 100% accuracy
and follows 2 step directions with 100% accuracy.
Approximates single word spelling at the 6.0 grade
level (KTEA). Generates simple written sentences
without difficulty.
Cognitive Skills
Cognition falls within functional limits. Patient
functions at Rancho Los Amigos Level VIII (Purposeful
Appropriate). The patient attended to a 1 hour evaluation,
without need for redirection by the therapist. Retained
task instructions without difficulty. Spelling and
written language are functional for communication
purposes. The patient had maintained previously
mastered Morse code skills. Identified logical codes
to abbreviate messages. Codes did not follow consistent
format. However, patient retained codes after a
20-minute time delay.
The patient initiates conversation
(by tapping finger, pressing buzzer). Comments or
questions appropriate to topic. Maintains topic
without difficulty.
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III. DAILY COMMUNICATION NEEDS
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A. Specific Daily Communication Needs
Primary communication situations
involve 1:1 and group conversations.
Primary communication environments
are home and day program. Patient also expresses
a desire to communicate at church and has opportunities
to go into the community with mother.
Patient's primary communication
partners include his mother, caregivers, extended
family, and staff at day program.
Patient's daily functional communication
needs requirement to communicate messages that convey
basic needs to various partners and provide direction
to caregivers who are less familiar with his needs.
He also needs to choose activities, express interests
and give opinions.
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B. Ability to Meet Communication Needs with non
SGD Treatment Approaches
The patient received
traditional speech language therapy immediately
following his injury when he was an inpatient in
an acute rehabilitation hospital. Medical records
indicate the patient received approximately 1 hour
of therapy/day for approximately 6 weeks. The records
indicate that no significant changes were noted
in oral motor function, however language and cognitive
abilities showed moderate improvement. Subsequent
screenings, conducted at least annually in outpatient
clinics, reported no functional improvements in
oral motor function. Given the current severity
of the patient's speech, medical diagnosis, and
time post onset, prognosis for developing functional
speech is judged to be poor.
Patient has had Light Talker
for approximately 10 years. Accessed device through
Morse code. Device is old and no longer functioning
on a consistent basis. Device is no longer manufactured
and very difficult to obtain repairs. When Light
Talker was operational, patient relied on the device
as his primary means of communication.
Currently, the patient relies
on yes/no responses (slight nod and eye brows up
for "yes"; slight shake of head for "no");
facial expressions, and spelled messages using Morse
code (uses thumb and index finger of right hand
to simulate "dots" & "dashes").
Also has buzzer that gives auditory feedback. The
patient uses yes/no responses and facial expressions
to indicate very basic needs to trained and familiar
caregivers. Use of Morse code with his fingers or
the buzzer is only effective with people who know
Morse code (i.e. the patient's mother).
The patient's current communication
approaches do not permit him to convey the type
and complexity of messages in the environments and
with those partners with whom he interacts on a
daily basis. Currently the patient is dependent
on his mother for interpreting all novel communication
needs.
A low technology solution, such
as an alphabet board, is not appropriate for this
patient because he is blind. The patient's speaking
needs cannot be met using natural communication
methods or low-technology approaches. The patient
requires SGD to meet his functional communication
goals.
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IV. FUNCTIONAL COMMUNICATION GOALS
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Upon receipt of an SGD, therapy
will target the following goals. The patient will
demonstrate ability to:
-
Convey basic needs to caregivers,
by spelling or retrieving preprogrammed message
on SGD, independently and with 100% accuracy
(to be met within 2 weeks).
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Communicate complex needs
and ideas, through the SGD, during face-to-face
and group social situations, independently and
with 100% accuracy (to be met in 1 month).
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Communicate needs and ideas
to a range of partners in various communication
situations, using various strategies to expedite
message production, independently and with 100%
accuracy (3 months)
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V. RATIONALE FOR DEVICE SELECTION
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A. General Features of the Recommended SGD and
Accessories
The SGD needs the following
input and output features:
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Input: 2 switch Morse code
input, accessible from both wheelchairs, alphabet
based with access to stored messages (i.e. abbreviation
expansion).
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Output: Text-to-speech speech
synthesis (given that patient has novel message
needs and is relying on spelling as primary
means to generate messages), auditory feedback.
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Other features: Portable
to accommodate conversational needs in various
locations with home and community. Long lasting
battery to ensure device is operational in various
locations and to minimize need to be close to
electrical outlet. Wheelchair and switch mounts
that allow access to SGD.
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B. Recommended Medicare Device Category and Accessory
Codes
The individual's ability to
meet daily communication needs will benefit from
acquisition and use of the SGD Category 5 (K0545).
The patient's family has a laptop computer that
he can use when he obtains appropriate communication
software. The patient also requires wheelchair and
switch mounting systems (K0546) and switches (KO547)
to access the SGD.
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C. Trials with SGDs and Accessories
After demonstration only, the
patient successfully used EZ Keys software with
Morse code to generate novel, sentence length messages.
The patient required occasional cues to toggle between
the word processor and side-talk. As the patient
becomes familiar with the operational requirements
of the program, it is anticipated that he will perform
this function independently. The patient also needed
occasional cues to use strategies to expedite message
production (e.g. abbreviating words, shortening
messages). Cues were required because cognitively,
the patient has difficulty shifting or alternating
his attention from generating complete text to simplifying
text. The fact that the patient needs cues has no
impact on the understandability of the messages
he produces; the strategies only influence the rate
of message production.
The caregiver successfully interpreted
all of the patient's messages relying on synthesized
speech output. Because the patient needs Morse code
access, the trial was limited to the EZ Keys program.
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D. Recommended SGD and Accessories
The patient will use his family's
laptop computer and his current switching system.
It is recommended that he be fitted with:
1. * EZ Keys -a software program
that offers all required features and will enable
the individual to achieve the designated functional
communication goals.
| EZKWIN |
EZKeys with
Voice Output for Windows |
2. Patient also requires
two AbleNet Specs switches for access to the SGD.
| (2)
SPECS |
2 AbleNet Specs
Switches |
3. Patient also requires a wheelchair
mounting system. The mount is required for efficient
and independent access, as well as to secure the
SGD and keep it stable.
Mount specifications are as
follows:
|
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*Slim Armstrong Switch Mount:
| SLIMARM |
Slim Armstrong
Switch Mounting System |
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*DaeSSy Frame clamp to adapt
current mount arm to fit on the patient's manual
wheelchair :
| UFC1000IP
and UFCOP |
Frame Clamp Inner Piece
and Outer Piece for 1" diameter tubing |
*DaeSSy Laptop mount plate to
securely attach the communication system to the
mount arm
| PC-COMP/QRP1 |
PC laptop holder (must
specify make/model of laptop at order) |
|
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*EZ Keys and Mount are available
from:
Words+, Inc Phone: (805) 266-8500 x112
40015 Sierra Hwy, Bldg B-145 FAX: (805) 266-8969
Palmdale, CA 93550
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E. Patient and Family support of SGD
The patient and his mother have
used an SGD in the past. With training and support,
the caregiver will be able to maintain the equipment.
Given the patient's proficiency with Morse Code,
he recognized that EZ Keys is the optimal device
for his needs.
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F. Physician involvement statement
A copy of this report has been
forwarded to the patient's treating physician (DR.
… #XXX) on ______ (date) for review and prescription.
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VI. TREATMENT PLAN
Upon receipt of SGD recommend
6-8 individual one hour sessions for patient adaptation
and training for augmentative alternative communication
(AAC) are recommended. Sessions will focus on the
functional communication goals identified in Section
IV.
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VIII. SIGNATURES /SLP ASSURANCE OF FINANCIAL INDEPENDENCE
The Speech-Language Pathologist
performing this evaluation is not an employee of and
does not have a financial relationship with the supplier
of the SGD.
____________________
XXX MS CCC-S
Speech Language Pathologist
ASHA #
State Lic.
Note: Signatures of other team members are not required
by Medicare, but should be included when available.
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2. Example of individual
with Moderate Receptive Aphasia, Severe Expressive
Aphasia and Moderate Apraxia of Speech
Facility Name
Department of Speech-Language Pathology
Facility Address and Phone Numbers
MEDICARE FUNDING
REQUEST
FOR SPEECH GENERATING DEVICE (SGD)
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I. DEMOGRAPHIC INFORMATION
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Patient's
Name:Jack Doe
Date of Birth:0/00/45
Address: |
Social
Security #:
Phone Numbers |
Patient's Primary Contact Person:
Address: |
Relationship to Patient:
Phone Numbers: |
| Medical
Diagnosis: Cerebrovascular Accident (CVA) |
Date
of Onset: 2-25-98
Date of Evaluation: |
Date of Request: |
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Physician:
Speech-Language Pathologist:
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Phone Number:
Phone Number:
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II. CURRENT COMMUNICATION IMPAIRMENT
A. General Statement
Impairment Type & Severity
(ICD-9 Diagnostic Code: 784.5, 784.69)
As a result of a sudden onset left unilateral
CVA in 1998, patient, age 55 years, presents with a moderate
receptive and severe expressive aphasia across all modalities
with concomitant moderate apraxia of speech.
Mr. ____(Patient) is functionally non-speaking.
Patient's primary means of communication are inconsistent
gestures, facial expressions, exaggerated changes in vocal
intonation, and inconsistent yes/no head nods.
Anticipated Course of Impairment
: Aphasia and apraxia are
judged to be stable and chronic in nature.
B. Comprehensive Assessment
Hearing
Family denies hearing problems
for patient or primary communication partners. Patient passes
bilateral pure tone audiometric screening at 25 dB for octave
frequencies from 500-4,000 HZ . Attends and responds to
auditory information presented at conversational loudness
levels. Understands digitized speech and good quality synthetic
speech equally well as judged by appropriate responses and
reactions to message output. Possesses hearing abilities
to effectively use SGD to communicate functionally.
Vision Patient
wears bifocals. Corrected visual acuity is within normal
limits. No other visual impairments are noted. Discriminates
12-point font and 1/2 inch symbols on SGDs. Patient possesses
visual skills to use SGD functionally.
Physical
Patient demonstrates moderate right hemiplegia with minimal
use of right upper extremity (formerly dominant hand). Ambulates
using a quad cane. Safely carries small items (< 5 lb.)
with a shoulder strap. Uses a manual wheelchair for ambulating
long distances. Does not propel wheelchair independently.
Patient can independently access SGD with left arm/hand
and depress keys with left index finger. Demonstrates adequate
movement and pressure to activate both a membrane keyboard
and touch screen. Possesses physical ability to independently
and effectively carry, maintain, and access SGD.
Language Skills
Patient demonstrates moderate receptive
and severe expressive aphasia and concomitant moderate apraxia
of speech as formally measured on the Western Aphasia Battery:
Overall Aphasia Quotient: 18.8/100
Spontaneous Speech Score: 1/20
Auditory Comprehension Score: 8.4/10
Naming Score: 0/10
Reading: 28/100
Writing: 20.5/100
Informally, patient demonstrates functional
understanding of basic adult conversation, presented at
moderate rates. Comprehension improves when gestural and
written cues are provided.
Patient demonstrates ability to manage
SGD displays with 30 items. Identifies printed words on
a display of 30 with 50% accuracy. Rate of selection is
slow, frequently taking > one minute. When printed words
are enhanced with picture symbols on a display of 30, the
patient demonstrates 90% accuracy with functional selection
rates. Demonstrates ability to spell some functional words.
Uses word prediction with 80% accuracy, but rate of selection
is > 30 seconds (choice of 10 words).
During a 2-hour evaluation, the patient
masters independent use of up to 30 categories to access
30 screens of vocabulary/stored phrases (20-30 symbols/screen).
Spontaneously uses vocabulary to answer questions or establish
a topic, but does not formulate two or three- part messages.
Cognitive
Skills
No formal testing was conducted due to severity of patient's
aphasia and language demands of standardized tests. Informally,
the patient shows excellent attention and motivation to
communication tasks over a 2-hour period. Recalls symbol
locations and device operations/instructions. Initiates
communication spontaneously and manages basic operations
on/off/delete independently. Possesses linguistic and cognitive
ability to use SGD to communicate functionally.
III. DAILY COMMUNICATION NEEDS
A. Specific Communication Needs
Primary communication situations involve
1:1 and small group conversations.
Primary communication environments are
home, telephone (emergency and exchange with grown children
who live out of town), and community.
Patient's primary communication partners
include his wife, family, friends, and health professionals.
Patient needs to communicate messages
that provide identifying/biographical information, express
physical status/needs, socialize, offer information about
past and present experiences, and express feelings and opinions
with familiar and unfamiliar communication partners across
multiple environments.
B. Ability to Meet Communication Needs With Non-SGD Treatment
Approaches
Patient has not shown speech improvement
with traditional speech language therapy (Weekly 1 hour
individual therapy 1998-2000). Given the time post onset
and current severity of the patient's expressive aphasia
and apraxia of speech, the patient is judged to have minimal
to no potential to develop speech. Patient does not have
adequate spelling skills to support writing as primary mode
for expressive communication.
Currently, patient is limited to communicating
about objects/activities in the immediate environment (points
to them), confirming or rejecting (fair reliability), answering
some questions related to needs by pointing to written choices,
and relying on family members' interpretations of vocalizations
and facial expressions. Patient has attempted to use a word/picture
communication book, but found that either vocabulary was
too limiting or when additional vocabulary pages were added,
one-handed page turning with the left/non-dominant hand
was cumbersome/nonfunctional
Patient lives at home with his wife.
She reports difficulty understanding patient's requests
for specific items. She notes patient is limited in his
ability to communicate with other family members and friends.
Patient's inability to communicate on the phone interferes
with his potential to maintain contact with his two children
who are away at college.
As a result, Mr. ____daily functional
communication needs cannot be met using natural communication
methods or low-tech/no-tech AAC techniques.
IV. FUNCTIONAL COMMUNICATION GOALS
Upon receipt of an SGD, treatment goals
will target use of SGD in face-to-face interactions, on
the telephone, and in daily communication situations to
spontaneously:
- Provide identifying/biographical
information to familiar partners on 8/10 opportunities
(within 1 month)
- Offer information about present or
past events to familiar and unfamiliar partners on 8/10
opportunities (within 3 months)
- Express feelings and opinions
to familiar and unfamiliar partners on 8/10 opportunities
(within 3 months).
V. RATIONALE FOR DEVICE SELECTION
A. General Features of Recommended SGD and Accessories
Based on the above noted comprehensive
assessment, daily communication needs, and functional communication
goals, the patient requires SGD with the following features:
Input/Message Characteristic Features:
- Visual word/picture symbol displays
for minimum of 30 symbols
- Dynamic touch screen/direct selection
and categorical encoding
- Minimum 50 levels on which to store
extensive vocabulary/messages
- Pre-programmed dictionary of functional
vocabulary
- Word prediction
Output:
- Synthesized voice output/text to
speech capability
Other features:
- Lightweight (e.g. < 5 lb) and
portable with shoulder strap/independent patient transport
- Minimum battery time 4 hours to insure
availability.
Accessories
- Carrying case so device can be transported
safely and independently
- Back-up Card that enables custom
vocabulary displays to be backed up and retrieved if necessary
B. Recommended Medicare Device Category and Accessory
Codes
The individual's ability to meet daily
communication needs will benefit from acquisition and use
of the SGD Category K0544 and accessories (carrying case
and backup card) from SGD Accessory Code K0547.
C. Trial with SGDs
The patient and his wife participated
in a two-hour evaluation. The patient was introduced to
a variety of SGDs which offer word/picture displays and
voice output including: TechTalk 8, Handheld Voice, MessageMate,
Dynamo, DynaMyte, and DynaVox 3100. The patient is able
to access all SGDs. Patient's needs and abilities exceed
the available vocabulary on the TechTalk8, Voice, and MessageMate.
With >20 words/symbols on a Dynamo display, symbols are
unclear and interfered with patient's symbol selection accuracy
and rate. The DynaVox exceeds size/weight criteria for the
patient to carry it independently/safely.
With the DynaMyte, patient demonstrates
ability to use a personalized screen to provide 20 items
regarding identifying/biographical information (name, address,
phone, family members, education/work history, etc.). Navigates
between 30 screens on verbal command with 70% accuracy.
Answers object function wh-questions with 75% accuracy.
Offers information for picture description activity with
70% accuracy. Expresses feelings/opinions with 60% accuracy.
Uses Child User dictionary two times to find vocabulary
not available on custom screens. Functionally types/uses
word prediction for 12 words in conversation. In addition,
he demonstrated an ability to use the carrying case to transport
the device.
D. SGD and Accessories Recommendation
Based on SGD trials, it is recommended
that the patient be fitted with:
(KO544) DynaMyte 3100-to improve functional
communication.
(KO547) DynaMyte Carrying Case (CC-DMYT)-to protect SGD
in transit.
(KO547) DynaVox Back-up Card (DMYT-BU16)-to back-up custom
vocabulary.
These items are available from:
DynaVox Systems, Inc.
2100 Wharton Street
Pittsburgh, PA 15203
1-888-697-7332
E. Patient and Family Support of SGD
The patient is highly motivated
to use an SGD to improve his communication. His wife supports
the use of the DynaMyte and demonstrates good entry-level
ability to program the DynaMyte. With additional training
and support, the wife will be able to independently program
and maintain the equipment.
F. Physician Involvement Statement
A copy of this report has been forwarded
to the patient's treating physician (DR. … #XXX) on
______ (date) for review and prescription.
VI. TREATMENT PLAN
Upon receipt of SGD, it is recommended
that the patient receive 8 one-hour individual and 8 one-hour
small group patient therapy sessions within 3 months. These
sessions will address goals listed in Section IV of this
report. An additional two hours of training are recommended
to further train the patient's wife to program and maintain
the device.
VIII. SIGNATURES / SLP ASSURANCE OF FINANCIAL INDEPENDENCE
The Speech-Language Pathologist performing
this evaluation is not an employee of and does not have
a financial relationship with the supplier of the SGD.
____________________
XXX MS CCC-S
Speech Language Pathologist
ASHA #
State Lic.
Note: Signatures of other team members are not required
by Medicare, but should be included when available.
Return
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3. Example of individual
with Severe Aphaisa and Severe Apraxia of Speech
Facility Name
Department of Speech-Language Pathology
Facility Address and Phone Numbers
MEDICARE FUNDING
REQUEST
FOR SPEECH GENERATING DEVICE (SGD)
|
I. DEMOGRAPHIC INFORMATION
|
Patient's
Name: Jack Doe
Date of Birth: 0/00/35
Address: |
Social
Security #:
Phone Numbers: |
|
Patient's Primary Contact Person:
Address:
|
Relationship to Patient:
Phone Numbers:
|
| Medical
Diagnosis: Post ruptured cerebral aneurysm and
hypoxic episode |
Date
of Onset: 2-25-93
Date of Evaluation:
|
Date of Request: |
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Physician:
Speech-Language Pathologist:
|
Phone Number:
Phone Number:
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II. CURRENT COMMUNICATION IMPAIRMENT
A. General Statement
Impairment Type & Severity
(ICD-9 Diagnostic Code: 784.3)
As a result of a sudden-onset ruptured cerebral aneurysm
and subsequent hypoxic episode in 1993, Mr. ___, age 66
years, presents with aphasia across all modalities and concomitant
apraxia of speech. Mr. ___(Patient) is functionally non-speaking.
Patient's primary means of communication are inconsistent
gestures, exaggerated changes in vocal intonation, and inconsistent
yes/no head nods.
Anticipated
Course of Impairment: Aphasia is judged to be stable
and chronic in nature.
B. Comprehensive Assessment
Hearing
Family denies hearing problems for patient
or primary communication partners. Patient responds at screening
levels of 1000, 2000, and 4000 Hz bilaterally when tones
are presented at a cutoff level of 30dB in a quiet room.
Patient attends and responds to auditory information presented
at conversational loudness levels. Understands digitized
speech and good quality synthetic speech equally well as
judged by appropriate responses and reactions to message
output (80 % accuracy). Possesses hearing abilities to effectively
use SGD to communicate functionally.
Vision
No visual acuity problems are noted.
Patient demonstrates severe visual field cut in lower right
quadrant. Does not compensate unless cued. Demonstrates
best accuracy (85%) identifying picture symbols when ten
2-3" color symbols/display are presented in top-down
array or left of midline. Possesses visual skills to use
SGD functionally.
Physical
Patient ambulates for short distances
by cruising from furniture item to item. Spends 50% of day
in manual wheelchair. Moves independently to a table (potential
location of SGD) by ambulating or propelling his wheelchair.
In community environments, the patient will have the SGD
velcroed to a bean bag lap desk which he carries in his
lap.
Patient can independently access SGD
with left arm/hand and depress keys with left index finger.
Demonstrates adequate movement and pressure to activate
both a membrane keyboard and touch screen. Requires partner
assist to change levels/overlays on all devices. Possesses
physical ability to effectively use SGD.
Language
Skills
The patient demonstrates severe aphasia
and concomitant severe apraxia of speech as formally measured
on the Western Aphasia Battery:
Overall Aphasia Quotient: 11/100
Spontaneous Speech Score: 1/20
Auditory Comprehension Score: 2.5/10
Naming Score: 0.8/10
Reading: 15/100
Writing: 2.5/100
Because of the patient's limited ability
to communicate through text or speech, a symbol assessment
was conducted using an informal clinician-made task according
to criteria from Beukelman and Mirenda (1998) as well as
the Multimodal Communication Assessment Task for Aphasia
(Garrett, 1998). Results include:
- ability to identify familiar photos
of family members in response to name and contextual phrases
(85%)
- ability to identify color-enhanced
black and white line drawings of objects representing
daily needs and wants (e.g. peanut butter, bathrobe) in
response to name and contextual phrases (78%)
- ability to locate symbols given an
array of ten 2" symbols arranged vertically and/or
to the left (75%)
- ability to understand conversational
phrases stored on a digitized SGD when activating its
corresponding symbol as demonstrated by appropriate actions
and facial expressions (70%)
- ability to locate and activate symbols
and digitized messages in response to a realistic role-play
regarding needs or structured conversational questions
on SGD display containing ten symbols arranged by topic
and in top/bottom order given minimal cues/occasional
assistance (65%)
- inability to sequence symbols-therefore
messages would have to represented holophrastically.
In conversation, patient demonstrated
ability to follow basic commands and follow basic conversation
when gestural and written cues were provided.
Cognitive
Skills
The patient sustains attention
for up to one hour if communication partners facilitate
his understanding with use of gestural and written communication
cues. Recalls symbol locations on a display from session
to session. Attempts to initiate communication and independently
reaches for the SGD. Turns SGD On-Off independently. Possesses
linguistic and cognitive abilities to use basic SGD to communicate
functionally.
III. DAILY COMMUNICATION NEEDS
A. Specific Daily Communication Needs
Primary communication situations involve
1:1 and small group conversations.
Primary communication environments are
home, telephone (emergency and exchange with grown children
who live out of state), and to a lesser extent, community.
Patient's primary communication partners
include his wife, caregivers, family, and visitors.
Patient needs to communicate messages
that convey needs/physical problems/ pain, greetings and
basic social exchange, leisure activity choices, and information
about recent/past events to the primary communication partners
across communication environments.
B. Ability to Meet Communication Needs with Non-SGD Treatment
Patient has not shown speech improvement
with traditional speech- language therapy(1 hour individual
therapy, weekly/1993-4, 1 hour group therapy, weekly/1998
to present). Given the time post onset and current severity
of the patient's oral apraxia, apraxia of speech, and severe
aphasia, the patient is judged to have minimal to no potential
to develop speech. In addition, due to profound agraphia,
the patient did not write functional words except for his
signature.
Currently, the patient is limited to communicating about
objects in the immediate environment (picks them up), confirming
or rejecting (fair reliability), answering some questions
related to needs by pointing to written choices, and relying
on caregivers interpretations of vocalizations and facial
expressions. Patient's wife reports consistent difficulty
understanding patient's needs and interests. Patient has
experienced minimal improvements in functional communication
with a picture communication book. Points to picture to
establish topic, but remains dependent on wife to try to
interpret for self and others, as patient cannot formulate
complete messages. Patient's daily functional communication
needs can thus not be met by natural communication or low-tech/no-tech
augmentative communication.
IV. FUNCTIONAL COMMUNICATION GOALS
Upon receipt of SGD, treatment goals
will target use of multiple displays on SGD (6-8 symbols
per display) in real-life situations to*:
- Express needs/physical problems/pain
during interactions with family, caregivers and medical
personnel in person and on telephone with min/mod verbal
cues with 80% accuracy (within 1 month)
- Choose leisure activities with min/mod
verbal cues with 80% accuracy (within 1 month)
- Express greetings and social exchanges
with family and friends with min/mod verbal cues with
80% accuracy (within 1 month)
- Offer information about recent/past
events to familiar and unfamiliar partners with min/mod
verbal cues with 80% accuracy (within 2 months)
- Participate in phone conversation
with out of town family members with min/mod verbal cues
with 80% accuracy (within 2 months)
*The communication partner will consistently
be responsible for setting up the correct message level.
Development of these skills will provide patient opportunity
for increased control and socialization with a variety of
partners in numerous different communication situations.
V. RATIONALE FOR DEVICE SELECTION
A. General Features of Recommended SGD and Accessories
Based on the above noted comprehensive
assessment, daily communication needs, and functional communication
goals, the patient requires SGD with the following features:
Input/Message Characteristic Features:
- Membrane keyboard or touch screen
for direct selection with LUE
- Static display
- Large (1 ½ -2") color
picture symbols (Picture Communication Symbols or DynaSyms
and Words)
- Capability to create divisions/spaces
between pictures
- 10-12 levels on which to store messages
Output:
- Digitized (<8 minutes) or synthesized
voice output
Other features:
- Portable enough for caregiver to
carry in community
- Minimum battery time 2-4 hours to
ensure availability.
B. Recommended Medicare Device Category and Accessory
Codes
The individual's ability to meet daily
communication needs will benefit from acquisition and use
of the SGD Category K0541. No device accessories are required.
C. Trials with SGDs
The patient was seen for 3 individual
and 2 group therapy sessions using the Tech/TALK 8, Tech/speak,
MessageMate 40, and the DynaVox 3100c. The patient activates
all keyboards successfully. Becomes confused by displays
with more symbols (e.g. Tech/Speak and MessageMate 40).
On 6-8 large symbol displays, the patient increases the
frequency of his purposeful communication attempts, increases
his attention to peer speaker or clinician facilitator (from
40%-90%), and demonstrates success in locating messages
stored on an SGD to answer conversational questions and
make requests. Patient requires cues to scan display to
compensate for his right visual field cut. Does not use
categories to benefit from dynamic display. Does not formulate
two-part messages/sentences.
D. Recommended SGD and Accessories
Based on SGD trials, it is recommended
that the patient be fitted with the:
Tech/TALK 8 (xo7012)*- a portable digitized voice (6.4min
recording time) output device with 8 large words/pictures
per display and ability to store 12 levels/displays. This
device has features designated as necessary to achieve Mr.
____'s functional communication goals.
*Available from:
Mayer -Johnson Company
PO Box 1579
Solana Beach, CA 92075
800-588-4548
E. Patient and Family Support of SGD
The patient is highly motivated to use
an SGD to improve his communication. His wife supports the
use of the Tech/TALK 8 and demonstrates good entry level
ability to prepare overlays and program the device. With
additional training and support, the wife will be able to
independently program and maintain the equipment.
F. Physician Involvement
Statement
A copy of this report has been forwarded
to the patient's treating physician (DR. … #XXX) on
______ (date) for review and prescription.
VI. TREATMENT PLAN
Upon receipt of SGD, it is recommend
that the patient receive 45 minutes of individual therapy
and one hour of group therapy weekly for 8 weeks (total
16 sessions). These sessions will address goals listed in
Section IV of this report. An additional two hours of training
are recommended to train caregivers to program the device.
VIII. SIGNATURES / SLP ASSURANCE OF FINANCIAL INDEPENDENCE
The Speech-Language Pathologist performing
this evaluation is not an employee of and does not have
a financial relationship with the supplier of the SGD.
____________________
XXX MS CCC-S
Speech Language Pathologist
ASHA #
State Lic.
Note: Signatures of other team members are not required
by Medicare, but should be included when available.
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4. Example 70 YEAR OLD
WOMAN WITH PROFOUND DYSARTHRIA SECONDARY TO ALS
Facility
Name
Department of Speech-Language Pathology
Facility Address and Phone Numbers
MEDICARE FUNDING
REQUEST
FOR SPEECH GENERATING DEVICE (SGD)
|
I. DEMOGRAPHIC INFORMATION
|
Patient's
Name: Jane Doe
Date of Birth: 0/00/31
Address: |
Social
Security #:
Phone Numbers: |
|
Patient's Primary Contact Person:
Address:
|
Relationship to Patient:
Phone Numbers:
|
| Medical
Diagnosis: Amyotrophic Lateral Sclerosis |
Date of Onset: Diagnosed
July, 1999; first symptoms noted 4/99 in gait and balance
Date of Evaluation:
|
Date of Request: |
|
Physician:
Speech-Language Pathologist:
|
Phone Number:
Phone Number:
|
II. CURRENT COMMUNICATION IMPAIRMENT
A. General Statement
Impairment Type & Severity (ICD-9
Diagnostic Code: 784.3)
Secondary to ALS, Mrs. _____ presents
with a profound dysarthria and is functionally nonspeaking.
Produces differentiated vowels with varying intonation.
Imitates monosyllabic words, with referent known, with 10%
intelligibility.
Oral motor control limited to gross
movements only, and these movements are imprecise, reduced
in range and executed slowly (e.g. open - close mouth, protrude
tongue). Patient receives nutrition through gastrostomy
tube. Spontaneous speech is limited to vocalizations.
Anticipated Course of Impairment
Based on the Severe Dysarthria due to Amyotrophic Lateral
Sclerosis Staging Scale (a 5-point scale, with 1 being no
detectable speech disorder and 5 being no useful speech),
patient's speech is characteristic of Stage 5 - No useful
speech. Given the patient's current status and progressive
nature of ALS, it is anticipated that Mrs. ___'s condition
will deteriorate further.
B. Comprehensive Assessment
Hearing
No problems with hearing noted or reported.
Patient passes pure tone audiometric screening for octave
frequencies at 25 dB from 500- 4000 Hz. Attends to and discriminates
natural and synthetic speech at conversational loudness
levels. Husband may have slight hearing loss, although his
hearing has yet to be formally assessed. Husband successfully
discriminated synthetic speech n SGD, at sentence level,
given occasional repetition (of spoken message) and reliance
on visual display. Patient and primary communication partner
possess hearing abilities to effectively use SGD to communicate
functionally.
Vision
Patient wears bifocal glasses at all
times. Shows no problems with visual attention, scanning,
tracking, or acuity with glasses on. Discriminates ¼"
text on display positioned at midline, at a distance of
approximately 18", without difficulty. Possesses visual
abilities to effectively use SGD to communicate functionally.
Physical
The patient is wheelchair dependent.
Has an electric wheelchair (Jazzy 1100, with a right
joystick controller). Drives chair independently and safely.
Seating tolerance
approximates 2 -3 hours. Patient referred to physical therapist
for recommendations to
improve seating comfort and tolerance. Patient spends several
hours/day in a standard
recliner chair. Needs access to SGD from both wheelchair
and recliner.
Patient reports weakness in both upper
extremities. Patient is right hand dominant. Able
to type on standard keyboard using middle right finger and
left index finger. Types
quickly and with few errors. No indications of fatigue or
discomfort after typing several
sentences. Does not require keyguard at this point in time.
Accommodations may be
required as ALS progresses (e.g. keyguard, scanning module/switch).
Patient possesses
the physical abilities to effectively use a SGD with noted
accessories to communicate functionally.
Language Skills
Informal assessment reveals oral and
written language skills within functional limits. Patient
answers abstract yes/no questions with 100% accuracy and
follows multistage directions with 100% accuracy. Answers
multiple choice questions about a paragraph read silently
with 100% accuracy. Types grammatically correct, syntactically
complex sentences. Formulates meaningful written paragraphs
independently.
Cognitive Skills
Patient retains task instructions without
difficulty. Recalls 100% (5/5) of messages stored under
abbreviations. Identifies logical codes to abbreviate messages.
Spontaneously uses strategies to aid message production
(e.g. abbreviates words) Consistently gives partner feedback
(using SGD and nonverbal cues) to indicate if message is
accurately interpreted. Corrects and clarifies messages
as appropriate. Spontaneously and appropriately shifts between
communication approaches to maximize communication efficiency.
Demonstrates ability to use word prompting and prediction.
Possesses cognitive/linguistic abilities to effectively
use SGD to communicate and achieve functional goals.
III. DAILY COMMUNICATION NEEDS
A. Specific Daily Communication Needs
Primary communication situations involve
1:1 and small group situations. Primary environments are
home and medical appointments. Primary communication partners
include husband, daughter, friends, paid caregivers, and
medical staff. Specific message needs include expressing
needs, making requests, asking questions, offering information,
and expressing feelings/opinions. Patient expresses strong
desire to maintain her role as a decision maker in the home,
to socialize with friends and family, and to communicate
directly with medical staff regarding her disease and treatment.
B. Ability to Meet Communication Needs with Non-SGD Treatment
Patient has previously received speech
maintenance therapy. However, given the current
severity of the patient's speech impairment, coupled with
the progressive nature of ALS,
therapy to improve speech production is no longer indicated
or appropriate.
The patient relies on yes/no responses,
vocalizations, facial expressions, simple gestures
(e.g. pointing to items in environment), alphabet board
and desk top computer. Unaided
approaches are effective for calling attention and indicating
very basic needs
(e.g. pointing to a cup to request drink).
The alphabet board is used to generate
novel messages during face-to-face conversations with husband,
daughter and a few close friends. The board is adequate
for basic needs that require a 2 or 3 word message; messages
exceeding 2-3 words are difficult for partner to decode/retain.
The board also requires the partner to be standing beside
the patient as she composes her message. This can be tedious
and time consuming for all partners and is not tolerated
by medical personnel. The board is ineffective in-group
social situations, because not all partners can see the
board and follow along as the patient spells. The board
is not effective with hired caregivers because they cannot
read English. The desktop computer is used to prepare messages
in advance for either the husband or daughter. The computer
is not portable nor does it have voice output.
The patient's current communication
approaches do not permit her to convey the type and complexity
of information in the environments and with those partners
with whom she interacts on a daily (i.e. husband, daughter,
care givers) or intermittent basis (i.e. physicians, friends).
IV. FUNCTIONAL COMMUNICATION GOALS
Upon receipt of an SGD, therapy will
target the following goals. Ms.___(Patient) will:
- Demonstrate ability to master basic
maintenance and operations of SGD (on-off, adjusting menu
features such as voice and display) with 100% accuracy
(within 2 weeks)
- Demonstrate ability to program stored
messages independently with 100% accuracy (within 2 weeks)
- Convey basic needs/make requests
to caregivers, by spelling or retrieving pre-programmed
message on SGD, independently and with 100% accuracy (within
2 weeks).
- Initiate social greetings, offer
information, ask questions, express feelings and opinions
through spelling and retrieving stored messages on SGD,
during 1:1 and group situations with familiar and unfamiliar
partners, independently and with 100% accuracy (within
3 weeks).
- Use strategies on SGD to expedite
message production when sharing information or asking
questions of medical personnel, independently and with
100% accuracy (within 3 weeks).
V. RATIONALE FOR DEVICE SELECTION
A. General Features of Recommended SGD and Accessories
Based on the above noted comprehensive
assessment, daily communication needs, and functional communication
goals, the patient requires SGD with the following features:
Input/Message Characteristic Features:
- Direct selection with index and middle
fingers of both hands/standard or mini keyboard (patient
prefers QWERTY keyboard)
- Flexibility to accommodate changes
in physical access (i.e. alternative keyboard, scanning)
- Accessible from multiple positions
(i.e. wheelchair, Lazy Boy)
- Alphabet based with access to stored
messages (i.e. abbreviation expansion)
- Access to word prompting or prediction
to be used as physical access declines
Output:
- Text-to-speech speech synthesis (given
that patient has novel message needs and is relying on
spelling as primary means to generate messages)
- Two-way visual display to aid husband
(who has suspected hearing loss) to interpret messages
- Capability to facilitate communication
at a distance.
Other features:
- Portable to accommodate conversational
needs in various locations within home and at medical
appointments
- Long lasting battery to ensure device
is operational in various locations and to minimize need
to be close to electrical outlet.
B. Recommended Medicare Device Category and Accessories
Codes
The individual's ability to meet daily
communication needs will benefit from acquisition and use
of the SGD Category K0543 and equipment that enable device
to be mounted from SGD accessory code (K-0547).
C. Trials with SGDs
Patient participated in trials with
3 SGDs in Category K0543 that have the input and output
features similar to those delineated above. The SGDs included
DynaMyte/DynaVox 3100, the Link, and the LightWRITER SL35.
Both current and future communication needs were considered
as her physical condition is likely to deteriorate.
- DynaMyte/DynaVox 3100. Patient had
difficulty with glare and motor access on the DynaMyte
and DynaVox.
- Link. After demonstration only used
the Link to generate novel messages. Used all function
keys without difficulty. Given the battery limitations,
the inability to alter access methods, and the small visual
display the Link is not an optimal solution.
- LightWRITER SL35. The patient independently
utilized the LightWRITER to communicate her needs. Spelled
lengthy, complex messages without difficulty. Used function
keys with 100% accuracy and recalled all messages stored
under abbreviations. The husband successfully interpreted
all of the patient's messages relying on speech output
and the visual display. Any trial re: future features.
I think we should include something that relates to scanning,
e.g., patient was shown scanning features and was able
to select messages using linear scanning.
D. Recommended SGD and Accessories
Based on comprehensive assessment and
SGD trials, it is recommended that the patient be fitted
with the LightWRITER SL35 and wheelchair mount to secure
the device and allow independent access. The recommended
wheelchair mount is designed to accommodate the LightWRITER
and will enable her to use the device throughout most of
the day.
|
Part Number
|
Description
|
| SL35-LQFDO |
LightWRITER SL35 with dual fluorescent
screen, Qwerty keyboard and raised keys |
| 039-0319-01 MH-4 |
W/C Mini-Mount, 1'x2' tube, Pin
Release, 7/8" diameteria. Frame clamp |
| 039-0145-00 AF-55 |
GEWA Extrusion, 6", Tray Mount/Tube
Clamp |
LightWRTIER and accessories are available
from:
ZYGO Industries, Inc. 800 234?6006 or
503 684?6006
P.O. Box 1008 503 684?6011 fax
Portland, OR 97207?1008
E. Patient and Family Support of SGD
The patient and her husband demonstrate
motivation to maintain SGD. Have established basic skills
with the LightWRITER. The patient understood the pros/cons
of different devices and identified the LightWRITER as the
optimal device for her needs.
F. Physician Involvement Statement
A copy of this report has been forwarded
to the patient's treating physician (DR. … #XXX) on
______ (date) for review and prescription.
VI. TREATMENT PLAN
Upon receipt of SGD, it is recommend
that the patient receive 45 minutes of individual therapy
and one hour of group therapy weekly for 8 weeks (total
16 sessions). These sessions will address goals listed in
Section IV of this report. An additional two hours of training
are recommended to train caregivers to program the device.
V. SIGNATURES / SLP ASSURANCE OF FINANCIAL INDEPENDENCE
The Speech-Language Pathologist performing
this evaluation is not an employee of and does not have
a financial relationship with the supplier of the SGD.
____________________
XXX MS CCC-S
Speech Language Pathologist
ASHA #
State Lic.
Note: Signatures of other team members are not required
by Medicare, but should be included when available.
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