Chapters Transcript Video Augmentative and Alternative Communication: Solutions for Individuals with Communication Deficits Angela Strauch Lane, M.S. CCC-SPL presents at the Johns Hopkins Department of PM&R’s Grand Rounds on January 16, 2018. All right. So again, good afternoon and uh thank you so much for having me. Um I uh as as was mentioned by Dr Mayer, I am the Director of Assistive Technology at Unified Community Connections, but I'm also APR N speech language pathologist here at Johns Hopkins, which I still provide augmentative and alternative communication services for the A LS Assistive Technology Clinic started by Kelly Casey. So I do come in twice a month just for our folks with A LS to provide these devices uh device assessments. So we are going to talk today about augmentative and alternative communication or a AC solutions. So here is the nice long description, the American Speech Language Hearing Association um gives this definition to a ac most importantly, being that it attempts to take the place of or act as a supplement for communication for verbal communication. And we're going to get in specifically today to what are the different types of high technology and low technology devices that are available. So who does rely on augmentative and alternative communication? Well, you can be any age and have a communication impairment that requires some assistance to help you communicate successfully with others. You can be from any socioeconomic group, you can be rich, you can be poor and still have to rely on the aid of a communication system. All ethnic and racial backgrounds acquired and congenital disabilities, which we'll talk about a little bit more in a few minutes. And, um, you may have impaired speech production or be unable to speak completely. The unifying characteristic of all of these, uh, people who rely on a ac is that their written or spoken communication is somehow impaired and they need something to be able to uh supplement or take the place in surveys that have been done. The, the question has been asked to patients, why haven't you used an AC device before or why aren't you using an A AC device now? And the answer is not, they're so expensive. Um They're too hard to use. The answer is that they don't know that they exist. And so that's kind of what I want the presentation today to be about is to just give you knowledge of that augmentative communication exists. And how, what are the resources for being able to get these services for your patients? So, a ac is a really important aspect of communication. Someone who may be completely a phonic can't communicate verbally or dysarthria. So they're talking, but you have no idea what they're saying and they have to repeat and there's a lot of frustration. We want to use these devices over here and I'll show you those in a few minutes to try to take the place of that impaired speech. So a ac provides individuals with a form of interaction. Hey, I want to eat. I have pain. How are you doing? Just to be able to interact with others? It provides them with a means to participate in activities. So there could be something as a bingo going on down the hall and they're gonna be able to participate in shouting out that word. It's a means to develop social networks beyond their immediate families. And I think that this one is important, not when we're talking about our patients here in the hospital, not just the social networks but networks beyond their immediate families. So if someone, you know, you'll hear family say, I understand what he's saying. I know what he wants to say. I know what he needs. But when the patients are here in the hospital, we don't, can't always read that or the family members are not always available. So we need to have a means to be able to communicate with them effectively here and then give them that means in the future and then to support or obtain employment. So let's see if my video may not work today. We'll come back to that. Let's try one more time. It didn't work on my 2007 Power Point. So, well, it might be an issue here. So we'll come back to it. So there are various a ac language programs. So what is important about this augmentative communication devices offer a variety of programs to meet the cognitive and motor needs of the user. So you may be working with someone who has aphasia, maybe a receptive and expressive aphasia and they are not able to um spell or read. So we might need to use pictures to communicate for them. So this is a small device. This is called a Nova chat device, but it can be filled with pictures that provide, let me turn the volume up for you um that provide a form of communication. Go back baseball, simple things or hyper feelings, happy, sick, tired. It's just a way of being able to supplement um verbal communication. So there are different types of picture based devices the first time that is pretty simple, it's called a static display device. I think part of the problem is I mean your your presentation view. Oh, it did. OK, great. So if you notice with a static display device, the pages never change everything that the person will want to say or needs to say is right here on this page. So these types of devices are really simple and usually cost about $200. But what is nice is if you have some cognitive deficits, if you have some expressive language deficits, and it's hard for you to be able to navigate through different pages on the device. You can just press this and say what it is that you need to say these boards can be customized to the vocabulary that's essential for the individuals. So if I have someone who has language deficits and has difficulty with categorization or function of language, and again, a lot of our folks with aphasia and other um language deficits will see this, then we might want to stick with something as really simple as this device as a static display. I worked with an individual a few years ago with a severe expressive and receptive aphasia who was a lawyer and it was really hard for him to be able to go from being such a powerful lawyer to using a really simple communication device like this. But what he found out was, hey, at least if I am hitting these buttons on here, I'm able to get what I need and I'm able to have my needs met. So a static display is very simple. The other type of picture based device is a dynamic display I feel. Mm And so do you see how the pages are changing as the person is making a choice that is a dynamic display device which gives you many more opportunities for communication because you're gonna choose the category that you want and then it's gonna take you to a whole new page. So my patient does need to be able to categorize to understand, hey, if I hit the social page that's gonna give me social information or if I hit the I feel page, I'm gonna get my feelings. So for someone with a little bit of a, a lot higher level of cognition, they might be able to use a more sophisticated device like a static, a dynamic display. And these are the things that we determine during the A ac assessment. So picture based devices can be static or dynamic. There are also word based devices. So I'll use this frequently and I'll come right back for individuals who have pretty good cognitive skills but might have some motor deficits and then they can use whole words to communicate. They don't have to use just pictures. They don't have to type out every single word that they want to say. They can use. The What's nice about this program which is called word power. Word Power was created by Nancy Inman, formerly of Kennedy Krieger Institute. And what she did was she created a program so that your pronouns are on the left and then your actions are in the middle and your prepositions and your adverts are all on the right. So it's syntactically appropriate. So now someone can put a sentence together pretty quickly by saying by just hitting a few buttons, two go, I want to go. And then so if I want to go with the hit of four buttons, I was able to produce an entire set. So for someone who has um some difficulty, some motor deficits. I work with a lot of people with cerebral palsy and they can usually hit a button on here, but it would take them so long to type out a whole sentence. This is a nice way because of their motor deficits to be able to produce a sentence a little bit faster. There are also a lot of letter based communication devices that are available. So they give you a keyboard and you type out what you want to say, you can produce novel phrases using that be right back. One of the really nice jumps that augmentative communication has taken in the last few years is that there are several ipad apps that are available. So if someone owns an ipad, they can simply download an app to the ipad and have it as a communication device. I'm gonna show you an example of something that we recommend frequently. This app right here is called speak it. It's on the ipad and it costs $1.99 to download. So there's not a huge commitment. If it's something that a person wants to try, make sure my volume is up, so they can uh type out what they want to say, I'll do a quick sentence upside down and then I'll speak it. So again. So I'm asking how you are. I can type it out really quickly and then I can save these phrases for later if I want to be able to get to them quickly. So what is interesting to me is in the world of accessibility. If we're using voice recognition software, adapted equipment, Windows, computers tend to be doing a little bit better than Mac. The opposite is true for communication apps on an ipad, you have a lot more variety of communication apps available than you do on an Android device. So there are a few that are available on the Android and most of them are actually free. Um If you have a, if you have an interest, if you have an Android tablet, one, that's very good is called speech assistant. And that is word uh phrase and letter base. So you do have to be literate to use speech assistant, but that's just a resource for you. One other quick one, I want to show you on here that is available on the ipad that we recommend frequently. It's a nice long name. It's pro quo for text. If you're interested in it, I'll spell it very quickly. Pr Olo quo the number four and text. It's the same idea as speak it, but it costs 101 119 99. So it's more expensive. But the nice thing about um pro quote for text is you can type what you want to say. Here. There you go. All right, there we go. And then over here you have categories of phrases so you can save your phrases and have them in categories. So it's easier to get to them. So it's just a little bit more organized than speak it but speak. It is certainly for a dollar 99 is not a bad thing to have available on an ipad. So what does accessing an A ac device mean we want an individual to be able to access mode, motorically physically access a communication device. Not everyone can just take their finger and press the ipad. Like I just did motor deficits, visual deficits. So when I, when someone calls me and says I have someone that I want to recommend for an assessment, but I'm not sure he can hit the button. I'm not really sure how it's gonna work. I say we definitely want to see them. There are so many ways that individuals can access a communication device either through direct selection or scanning. Here are just some examples of direct selection methods. You can use a body part, any body part, you can use a stylus. This is I'm so sad. There's not a better picture than this one out there right now. But this is the best heads stick. I can find, I do still have some patients who love to use their heads sticks. I can't imagine they don't have back neck pain like crazy, but they find it to be a very consistent means of accessing their devices. There's a joystick. So if you can use a mouse or a USB joystick or a track ball. If you've seen them, you can plug them into your device. I'm gonna sneak over here again. Sorry, these devices have USB ports and I'm gonna talk a little bit more about the specific device in a moment. So you can just plug in a mouse, a joystick. And that's a method of access as well. A head tracker is also a method of access. So for someone who cannot use a body part to uh to access the device right up here is a camera. It's a head tracker specific head tracker. So you would take one of these silver dots, you put the silver dot on your head, on your nose in the middle of your glasses. And this camera, I feel happy. You feel so happy right now, this camera reads the movement of your head. So you're moving your head and I'll leave this up here. So certainly anyone interested. We can certainly try after. But I have the dot on my head, I'm moving my head around. I'm controlling the cursor on the screen and by simply dwelling for a second two seconds however long I need on my desired letter or picture. I'm making a choice so I can have no hand movement whatsoever. If I have pretty good head and neck movement, then head tracking might be a good answer. I feel happy for me. I'm really trying to stress that at least it's not this is boring. And then one of the relatively newer methods of access, if IES, we're using that a lot in the A LS clinic. And it is certainly becoming more a more popular access method. Yes, you'll start up in a moment. There are specific I devices that are out here. And I think I skipped over the part on the side where communication devices range from the $200 static display that I showed you up to a $16,000 I A system. Now we'll talk in just a moment about funding because there is a way to get access to these devices without paying $16,000. But on an IG system, this is just a Windows computer, it's a full functioning Windows computer. And this company who made this one Toby Dyna put their software on there and added a camera down here. I use my eyes and I calibrate the camera and then I can make choices on this device simply using my eyes. As a matter of fact, the less head movement the better. Because when we're moving, sometimes people try to get to the right and they're putting their head like this. We just want people keeping their heads still and straight and using their eyes to make choices. The camera is able to read the movement of the eye and can select, I'm in pain. I need to be turned. I want to discuss end of life decisions. There's a lot that people have to say. And using an ID system for someone with significant motor deficits is an option. There's also an indirect uh indirect access method. So scanning, if you've ever heard of it and I, I'll show you the video in one moment. Scanning is very accurate. If you use it, you'll probably do really well with it. But people tell me it is too slow. They can't stand it, but there is a way that they can access. I'm sorry, I keep leaving. Coming back with scanning, you're going to use a switch. It can be a small switch, a larger switch that's accessed via any body part. A gross motor hit an elbow, a knee, a foot as the device scans through each, each picture. When it gets to what you want, you're gonna choose it. So look right here. It's a little hard to see. This is the switch in this video. I'm going to hope the video plays, see it's scanning, hit the switch I want of vacation. Well, let's go of the be definitely. So that is scanning. The device automatically goes through each of the buttons, each of the pictures, each of the letters, each of the words. And when it gets to the one I want, I'm going to hit my switch. So you don't really need to have good fine motor skills to be able to access a switch because it could be a gross motor hit of the head of the foot, as I mentioned. So there are a variety of ways to be able to access augmentative communication devices and that's what we want our patients to know that there is definitely an option for them. Most people are able to find some way to access also for our physical therapy. Friends mounts are available so that the devices can be accessed from a wheelchair, a bed, uh or just a chair you can see on that far one that the wheelchair mount is connected to the wheelchair. So wherever the patient goes, the device is with them over here is a rolling mount which works perfectly if they're in their recliner. If they're laying in bed, you can roll it under the bed. So there's ways for a person to be able to have their device with them at all times before I get into um what's going on with a ac devices at Johns Hopkins. I just want to show you a couple more simple things and I'll bring them over a couple more or a lot more. First of all, I just showed you the eye gaze device, which is pretty big, right? So we would want eye gaze devices are usually used by people who cannot walk, who have significant motor deficits. And eye gaze is their only feasible means of access. So it's pretty big. It's a big device to carry around all the time. Communication devices can be as small as this Samsung device which is the size of a phone and it can still have a communication program on there. You should turn up the light heard is the line hostile, hostile. So they can be very small and it can be carried around with them or they can be a little bit of a lower technology. One of the devices that we recommend frequently is down is the boogie board and this is a nice low tech system for individuals who are in the hospital and can write, able to use. The boogie board is available on Amazon for 8 $20. It's also available at Brookstone if you are old enough and I'm sure not all of you are old enough to remember the edge of sketch. It's similar to that. So instead of having paper, paper, you can use this boogie board and I can say what I want to say, can you see it written on there at all? Closer when you're with the person you'll be able to see. So it says hello, I'm being friendly today. And now when I just hit this button up here, it has erased the whole screen. So I don't have to have pages and pages when there's something I want to be able to say, I write it on here quickly, you read it and I erase it. I've even got a little cover with my boogie board so I can carry the device and the stylist with me and use it for simple communication. This is called a flip and talk and also created by Nancy. And uh when she was at Kennedy Krieger Institute, speech, pathologist, flip and talks are nice things that are available uh in some hospitals as well because you can create this board, you can get this board for about $30. And let me just put my here is your main communication, your core words want help me go. So you're choosing down here and then up here there are all these different tabs. So if there are things that you need, if I go to the clothing page, I choose the clothing tab, I flip it over and I can tell you what clothing I want. So this is low technology, it's not going to talk. But if there's someone who needs their immediate needs met, this is a, a very simple low tech way. And then the last low technology device I'm gonna show you is called the talk track and the talk track is actually a watch. Well, it's a watch because it's worn that way. And it allows you to have four communication messages on here. So if there are things, people need to say quickly, turn me, I'm hungry. I can't breathe. I need help. They can have this watch with them at all times. For those of you who may work outpatient. Uh I worked with an individual once who was able to communicate his basic needs. If he was hungry, he gave us the gesture. If he felt sick, we kind of knew. But he wasn't able to communicate those important stories in his life. My dad took me to the baseball game this weekend. My dad had knee surgery, things that he really wants to tell. So we would program very personal messages on here that he was then able to share with his day program or with his friends and it could be changed very easily each day so that he had new information to share. So communication devices are very important for those essential uh things that you need to communicate pain emergency needs, wants. And then the whole other side of that is the social aspect and interaction and being able to share information. So how are uh get my boogie board? How are communication devices being used currently at Johns Hopkins, the inpatient acute care unit currently has three Toby C 12 devices that have I gaze access on them to BC twelves are a little bit of an older device. But the nice thing is they work there a way for people to be able to communicate uh successfully in an area where they they need to have that um that ipads with communication apps are located in acute care and outpatient rehab. Along with some of the lower technology devices, device is similar to this go. Talks are available. A nice easy static display device, switches are available and they um the sign out sheet for those is admired too in your office. Is that right? In Kelly Casey's office there? And then there was an IC U study looking at the use of IGA devices that was completed here at Johns Hopkins. So here were the methods that were used. Um a sample of patients in the medical IC U Surgical IC U and Neurosciences Critical care Unit were all enrolled. They participated in five guided sessions of using an eye tracking device. And then the psychosocial impact of assistive devices scale was given. So here you are, you get to use this IG system to tell us how you feel and what you want and what you need. So what were the outcomes, the results that were that patients were able to use these eye gaze devices to communicate needs? Great. Isn't that one step greater than not being able to communicate your needs? Delirium was present in four patients at recruitment but none after training, this I think is interesting. Also the device's overall um psychosocial impact range from neutral to strongly positive. Well, that's good because there was no harm, right? People either didn't have a strong opinion or felt like it was a nice um something nice to be able to use to communicate and patients exposed to eye tracking computers demonstrated a positive mean overall impact score. And this um study was completed by some of you in this room. So there really is a lot of hands on with a ac going on in Hopkins and hopefully that will certainly continue. So who completes a ac assessments in order for communication devices to be funded by health insurance, a licensed and certified speech language pathologist must complete the assessment. Now. That doesn't mean that ot is not greatly needed and appreciated to come in and help us with the access or a physical therapist isn't needed and appreciated to help with mounting of the devices. But a speech language pathologist must do the assessment and write the report. And the reason was in 2001, Medicare started paying for these communication devices and they said language is the most important aspect of this device. So we need someone with some knowledge and language to do the assessment. So any speech language pathologist who does an assessment should have a knowledge of a ac devices and the funding process and the assessment. So I wanna just give you an overview of the funding for a ac devices because this is kind of important, especially for those of you who work with inpatient in order for an ac device to be funded via health insurance, Medicare, Maryland, medical assistance or other medical assistance. Um private insurance, the patient must be living in what's considered to be his or her own home. And the reason for this is Medicare again, the guiding force that says if someone is in the hospital or in a long or short term care facility or a nursing home or a hospice program, we Medicare are paying for them to be there. So, or, or we, the insurance company paying for them to be there. So the hospital or the nursing home should be providing everything the individual needs. I think we could really debate that for a very long time. The bottom line is if a person is in hospital, if they're in any type of long term care, rehab, a nursing home sniff, even if they have hospice services in their own home insurance is not going to pay for the purchase of a device. So how does that affect all of you who work with inpatient? The oh, I I don't wanna say that yet. I'm gonna say something else. I'm gonna come back to that. So how does this affect you? What is really important is knowing where to refer and how to refer? And I'm gonna show you that slide in a minute. I just wanted to say that first. So funding a ac devices, the speech language pathologist must complete an assessment. We have to get a doctor's prescription and other paperwork. So it is truly a process to get the funding packet together. And then once we send it in for funding Medicare will typically pay for 80% of the cost. So 80% of the $16,000 device is going to be covered by Medicare, Maryland Medical assistance. And you know, you know, Mary medical assistance is state run. So each state might be different. But here in Maryland, they will typically pay 100% of the device cost. And then private insurance varies based on policy, but frequently it's 80% after a deductible is met. So if you have Medicare and medical assistance, your whole device is funded. If you have Medicare and a secondary insurance, your whole device will most likely be funded. So we absolutely have funding options available. What's really nice is going back over to here, as I mentioned before, this I gaze device specifically is a windows computer. You can see the desktop. Now, Medicare and the other insurance agencies say we're not going to pay for you to own a computer because they're concerned about fraud. So what they do is they lock all of the computer features, the the manufacturers of these devices, lock all of the computer features before the device is funded. So when this device arrives at your home, I thought I started that. It's only a communication system. You can't get to the internet, you can't get to your email. But wait, there's a trick. So once the device comes to your home for a $50 fee, uh depending on the company, this company because the company is $50. This one's only 25 you call the manufacturer, you pay them $25 and they will give you an unlock code. So then all of a sudden the device is unlocked. It's a full functioning computer system and I don't know why this one doesn't want to start up and you can email using this. You can connect your phone via Bluetooth. You can use, if you're using I gaze, you can use, I gaze to Skype to text message to make telephone calls to change the channels on your television. So once it becomes that full functioning computer, you now have access to verbal and written communication a few years ago. Uh just very quickly, they um there was Medicare, the centers for Medicare and Medicaid decided they weren't going to ever allow you allow you to unlock your device. And there was a big fight saying, don't people communicate written, don't people use written communication to talk to their doctors. Don't we need to have communication outside of our small circle that's in our homes. And so that was actually um overturned. And so now we can get full functioning computers for individuals because communication is so important in our lives right now. So just a few more things. So when should you refer for an a ac assessment? If a patient is unable to communicate verbally due to a variety of reasons, then it they could benefit from an A ac assessment. Now, I didn't say they could benefit from an A AC device because we don't know that for sure until we've actually met with them complete the assessment kind of got their view on how they feel about it and see if it's something that could meet their needs. It's also really good to refer if a person has limited speech or language output or is difficult to understand. So the referral process that's not too hard. If we have difficulty understanding someone or if they're unable to communicate, then this is a good way to go. Even if a patient is not in his own home, the assessment process can still take place. So if someone is in the hospital, for example, speech language pathologists here could use low technology devices to determine if the patient is able to identify pictures, if they can use simple communication methods and then will know that maybe once they leave the hospital, they could have a full assessment and get the device funded. You can provide the patient or family with contact information of an A ac evaluator and assist the family and patient in understanding the importance of a AC in daily life. This is a an assistive technology handout that was actually created by Kelly Casey, the director of our A T clinic. And this is a really nice referral form that is available on the ID drive or we could have you send it out to everyone in PM and R uh that just gives, that's a nice thing to hand to your patients or your patients families. So what is a system of technology. And Kelly used nice simple wording so that people who are not familiar with augmentative communication would hopefully be able to understand what is on here. So it just tells you some of the different types of communication. And then here are some referral possibilities. You're not gonna find a whole lot of people who do augmentative or speech language who specifically do augmentative and alternative communication. Any S LP can do the assessment as long as you have access to different communication devices, but here's just some general uh referrals and here is page three of it as well. Uh University of Maryland formerly is actually really starting to build up an assistive technology augmentative communication program there and they are seeing a lot of individuals and then the last resource up there is the Maryland Technology Assistance program, Maryland Tap, which is located in Baltimore and that is a state funded organization. They have a variety of communication devices that anyone can come and borrow for 30 days. So if you feel like you want to do an assessment or try with someone who's in the hospital, you can contact Marilyn Tap and borrow a device from them. So the last thing is uh a ac devices can empower those with communication deficits. Um This one kills me because we run into this way too much. There's no need for Saul's talker thing, Mister Psychologist, I can answer for him and that's really what we want to avoid. We want individuals to have a voice, even if it's a synthesized or computer generated voice, we want them to be able to make their own decisions and communicate those important matters in life. I do have different devices that are up here. If anyone at the end wants to play or touch or try. And I do also have some cards in case you want to contact me with any questions. But are there any questions right now? Yeah. Yes. When, when you're recording it. So when we're creating the vocabulary for them? Yeah, that's a great question. There are different methods for obtaining vocabulary just quickly one would be an interview, interviewing the family. What are this individual's most important uh people and activities? What are the things he needs to be able to communicate? Another one is called an ecological inventory where you're actually observing the individual in their day and seeing what they might come upon and what things they might have to be able to say and then putting that on there. So as a speech language pathologist, if I go and program your device today, it's not finished. There's gonna, it's gonna be continual. We like to train the families so that they could go back and add more vocabulary as the need arises. Yes. Are these devices related to other languages of Spanish or other? Yes. Good question to you. So a lot of devices, these higher technology devices now offer definitely Spanish. Um some are now coming out with French. If you're looking for a little bit of a, of a different maybe less popular language, you would want to consider using the ipad because believe it or not, the, the app on the ipads have more options for uh different languages. Yes. What do you suggest are on the inpatient side and devices and now? OK. What language um features or? Great. So one option is there are different device manufacturers. So you may have heard of and I've mentioned company Toby Dyna Saltillo, each of those companies have vendors, sales vendors who are very happy to come in even when a person is still in the hospital and trial some different devices with them. So they can't do in a but at least the patient and the therapist would be able to try word based or picture based or different language pages to see which one might work the best. Then it's not a bad idea because you can send the patient home with. Hey, you know what we trialed this device with this and it worked pretty well for you. Make sure you tell whoever does the evaluation. So that's certainly one way another way would be introducing through low technology to see if you could at least kind of get an idea of what might work best for them. Any other questions? Thank you very much. Please feel free to come back. Can Created by Related Presenters Angela Strauch Lane, MS Ms. Angela Strauch Lane is a Speech Language Pathologist based out of Sparks, Maryland and her medical specialization is Speech-language Pathologist.
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