This is a transcript from our podcast episode published January 31st, 2022. The podcast episode is offered for .1 ASHA CEU (introductory level, professional area). This transcript is made available as a course accommodation for and is supplementary to this episode / course. This transcript is not intended to be used in place of the podcast episode with the exception of course accommodation. Please note: This transcript was created by robots. We do our best to proof read but there is always a chance we miss something. Find a typo? Email us anytime.
A special thanks to our Contributing Editor, Caitlin Akier, for reviewing and editing drafts of our transcripts. Her work helps keep our material accessible.
[00:00:00] Kate Grandbois: welcome to SLP Nerdcast. I’m Kate
[00:00:09] Amy Wonkka: and I'm Amy and we appreciate you tuning in. In our podcast. We review and provide commentary on resources, literature, and we discuss issues related to the field of speech language pathology.
[00:00:20] Kate Grandbois: You can use this podcast for ASHA CEUs. Visit our website for other courses, including live courses, blog posts and SLP masterclasses available for graduate level credit. SLP nerdcast is committed to improving continuing education in our field through affordable pricing and open access libraries. You can support our work by leaving a review, referring a friend, making a one-time contribution on our website or subscribing.
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We love hearing from our listeners and we can't wait to connect with you
[00:01:08] Amy Wonkka: And just a quick disclaimer. The contents of this episode are not meant to replace clinical advice. SLP Nerdcast, its hosts do not represent or endorse specific products or procedures mentioned during our episodes, unless otherwise stated. We are not PhDs, but we do research our material.
We do our best to provide a thorough review and a fair representation of each topic that we tackle. That being said, it's always likely that there's an article that we've missed or another perspective that we haven't shared. If you have something to add to the conversation, please email us. We love hearing from our listeners.
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Hello friends. Um, let's see, we'll give it another, like, there's still, there's a solid handful of people who still are not here yet. Um, but to those of you who are here, we're very excited to meet everyone. Um, this is our first, our first, uh, live podcast recording, obviously. Um, for those of you who are familiar with your SLP nerdcast dashboard, you may have seen that there are handouts available for download in your SLP Nerdcast account.
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Are you ready? Aim. This episode is being recorded in front of a live audience for the first time, which means there will be a Q and a at the end. And a recorded webinar version available to view if you are a visual learner, you can use this podcast for ASHA CEUS. To earn ASHA CEUs for attending this webinar or for listening to the podcast, head on over to our website, www.slpnerdcast.com and purchase ASHA CEU processing for either format.
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[00:05:17] Amy Wonkka: And just a quick disclaimer, the contents of this episode are not meant to replace clinical advice. SLP ner cast its hosts and guests do not represent or endorse specific products or procedures mentioned during our episodes, unless otherwise stated we are not PhDs, but we do research our material. We do our best to provide a thorough review and a fair representation of each topic that we tackle.
That being said, it's always likely that there's an article that we've missed or another perspective that we haven't shared. And if you have something to add to the conversation, please email us. We love hearing from you. Close captioning is available for both the live and recorded versions of this episode.
It is auto-generated captioning.
[00:05:54] Kate Grandbois: Perfect. Perfect. Okay. So our intro literally is so long. We apologize to [00:06:00] everybody we're going to work on it to make it shorter, but if you're joining us, it is because you are interested in learning more about AAC evaluations. Today is the third installment of our AAC evaluation series.
And today we focus on the daunting documentation and funding. We chose this topic because it's, um, this is a really difficult component of conducting AAC evaluations. To a lot of the individuals that I mentor this is one of the most daunting parts. We've already covered a lot of the clinical aspects related to AAC evaluations in previous episodes.
So if you need a refresher, we definitely recommend listening to those first, before jumping into this topic. In our first AAC evaluations episode, we reviewed areas of competency for AAC, including linguistic, operational, social, and strategic. Most of us in the AAC world are familiar with those. We also reviewed the importance of being a decision facilitator, not a decision decider, the decision decider, not a [00:07:00] decider, but decision decider sounds better.
Let's go with that. And we also reviewed the critical components of collaboration. In the second installment of this series, we focused on the feature matching process. So if you're gearing up to actually do your first AAC evaluation, what your student or client ne um, what, what you need to consider when working with your student or client and how the feature matching process actually works, definitely go back and take a listen to that episode.
And today is really going to focus on what happens after you've done the evaluation. So how did you document what you did? What are the funding considerations that you need to think about? Um, we have an outline prepared for today, but given that this is a live recording, we're going to take questions throughout the presentation.
So if we say something and you have a question, feel free to pop it in the Q and a portion of the zoom thing, uh, which brings us to today's learning objectives. Where are they? Let's see, [00:08:00] let's find them there they are. Okay. Learning objective number one, identify the purpose of AAC of AAC, evaluation, documentation.
Learning Objective, number two, identify the components of a well-written AAC evaluation. Learning objective, number three, identify the role of data collection and how it relates to results and recommendations and learning objective number four, describe ethical considerations throughout the evaluation and funding process.
And I skipped a slide before, but we also have to read our financial and nonfinancial disclosures. Kate that's me. I'm the owner and founder of Grandbois Therapy and Consulting LLC. And co-founder of SLP nerdcast. Amy is oh. I mean,
[00:08:39] Amy Wonkka: yeah, definitely. I am employee of a public school system, of Grandbois therapy and consulting and I'm co-founder of SLP Nerdcast.
[00:08:46] Kate Grandbois: Okay. And our nonfinancial disclosures. So we're both members of ASHA, SIG 12, and we both serve on the AAC advisory group for Massachusetts advocates for children. I am a member of the Berkshire association for behavior analysis and therapy, mass ABA, the [00:09:00] association for behavior analysis international and the corresponding speech pathology and applied behavior analysis special interest group.
Okay. Onto the fun stuff, take it away.
[00:09:10] Amy Wonkka: Thanks for sticking with us this long everybody. Um, all right. So what are the purposes of AAC evaluation documentation? I think, you know, it's important for us to realize that AAC evaluations are really different from your typical speech and language assessments. Uh, first of all they're related directly to a person's access to their basic human right to communicate.
Uh, AAC assessments are generally much more time intensive. They collect different pieces of information compared with a typical speech and language evaluation. And we'll go into more detail about that later in this episode. I think it's interesting to differentiate that in some circumstances, your AAC assessment is going to include a lot of the components that would be part of your typical speech and language eval.
It's just going to add additional content in [00:10:00] there. And as Kate mentioned, you know, your role as an evaluator is different. So you're not the sole decider. You're not determining eligibility. You're not the only person making a choice about what is the solution here. Uh, you're more, you know, a collector of facts.
And a decision facilitator. So you are helping facilitate discussions and thoughts, uh, between our clients, our caregivers, considering different environments, different communication tasks, um, and you know, the, the views of different stakeholders, all of these are really important components in an AAC assessment.
[00:10:36] Kate Grandbois: And you already touched on this second point here, documentation of access to a person's basic human right to communicate. And that's a really significant thing and significantly different from us. Irregular three-year evaluation.
[00:10:49] Amy Wonkka: Yeah. I mean, it's, it's really different. And when we think about documentation, we're not documenting slowly for funding.
We're documenting because we're capturing that moment [00:11:00] in time. Uh, this is important for generally the somewhat robust team that complex communicators tend to have supporting them. Uh, but also, you know, hopefully this information would follow your client if they move. If they go to a different speech pathologist, if they moved to a different town or state or country.
Um, so these documents are really important because not only are they a way for you to capture the clinical decision-making, which is an ethical issue, they're also representing a person's skills and documenting sort of their current communication profile and projected next steps. It's a big deal.
[00:11:37] Kate Grandbois: The really big deal.
I mean, think about a, for me, it's the moving piece. That's a main, that's always in the back of my mind when I'm writing up these assessments, because that piece of documentation and justification of a tool, especially when we get into funding, will travel with that person from place to place. And that's, that's a critical, critical piece.
[00:11:58] Amy Wonkka: And it's something that a family can [00:12:00] have. You know, it's a, it's a tangible piece of communication that they can then share with any other providers who, you know, they, they identify as important
[00:12:11] Kate Grandbois: The last one, the most obvious ones, documentation for funding.
[00:12:16] Amy Wonkka: So this again is different from your standard speech and language eval, right.
So the documentation we're providing in an AAC eval often is used to justify funding from some third party entity of some sort, right? So we are not only identifying needs or problem areas and potential solutions. We're making suggestions about this purchase of equipment and that equipment could be expensive.
I think less so in, I would say recent years for not that recent years, but since like 2012, at least. Um, so some of these things are, you know, available at the consumer level. Some of these things are not, and there's really specific guidelines depending upon your funding agency [00:13:00] and these guidelines vary tremendously, um, from entity to entity, it can vary based upon your client's insurance policy, um, across state lines. So it's, there's no one big master guideline in terms of, you must always include these components. So, so the one thing you must always do is research your funding source and what components they require for documenting.
I have a little story
[00:13:28] Kate Grandbois: to tell, are you ready? So I had a client, um, this was a couple of years ago, but it was a situation where they came to me already with a device and a previous SLP would that they were working with, according to the family had just verbally told them to purchase the equipment. Uh, because they had tried it in therapy and it went well.
And this is, you know, a typical situation we find when we're, you know, especially at least in my experience in AAC, where there are multiple providers, I might be in the school or I might be an [00:14:00] outpatient and don't have direct collaborative communication with either the prescribing SLP or the treating SLP or vice versa.
So I had no idea where this device had come from. I had no idea, um, what the feature matching process looked like. And there was no documentation that was done. I had no idea what the reasons for the device being chosen were, and the family had paid out of pocket for the device because there was no documentation to submit to the third party funding.
And they hadn't been educated about what the consumer process looks like. And so I had to ask myself, was this an ethics violation? This was a really difficult question for me to ask myself, was, was this an ethics violation? And to me, the answer is yes, it was an ethics violation for a couple of reasons.
So we have principle 1Q: individuals shall maintain timely and accurate records. I'm going to gloss over these really quickly. We also have principal 1H, individuals shall obtain informed consent from [00:15:00] persons. They serve about the nature and risks of the, of the, of treatment. Um, and it also potentially violates principle 2A where individuals who hold their C’s shall engage in only those aspects of the profession that are within their scope of competence. And so I, I tell that little story to just sort of reflect on the purpose of documentation for AAC assessments, because they are somewhat, they are substantially different than our previous assessments because they travel again, just to highlight that travel with the individual from, from location to location.
Um, Moving on though, the relationship between documentation and funding.
[00:15:41] Amy Wonkka: Right so funding is probably going to influence your documentation. Funding doesn't influence your determination around the most appropriate tool, but it is going to influence the words that you write on the paper and the components that you [00:16:00] need to be sure to include, or may not necessarily need to include in your write-up for funding.
So for example, certain insurance companies might require you to include a cost analysis or report specifically on pain or include data in a certain environment or set of environments. Um, your funding source might also include additional assessment steps. Like they might include, they might mandate written documentation from another professional.
I mean a physician prescription I feel like is a pretty common example of that. Um, some funding sources require a physician prescription, uh, funding may also dictate components of the assessment process. So it's important for you to identify the funding entity as an initial step in your AAC assessment process, because that makes sure that you gather all of the important pieces as part of your documentation moving forward.
Um, you really want to know at the beginning, if my funder [00:17:00] requires data collected, let's say in a community environment, I need to know that before I complete my assessment process so that I can have that data so that when it comes time to write up my evaluation, I'm not scrambling saying, oh no, last minute we need to also collect this data or worst case scenario you've returned the equipment to the vendor, and you're unable to collect that data in the environment that's required by the funding agency.
[00:17:24] Kate Grandbois: And I remember learning this from you way back in the day, when you, when you taught me how to do AAC evals and how confusing this can feel, some, are you cringing?
Cause you're like, oh, I don't remember when I did it, but this can be a really confusing process because you're supposed to consider your funding source, but you're also not supposed to let it influence your clinical decision-making because of all of these ethical issues with having a financial rep, having a relationship, having the finances, dictate or influence the feature matching process.
Tell us a little bit more about that, Amy. Cause I feel like you always [00:18:00] coached me so well through this and it can be really difficult to tease that.
[00:18:04] Amy Wonkka: Like you're building me up. I'm not sure. I'm not sure that I can deliver
Kate Grandbois: You always deliver I have nothing but faith in you
Amy Wonkka: oh boy. So I think that there are, there are pieces that are helpful, uh, going into the assessment.
You know, the way that my, that my brain works is I like to go on a couple of the different vendors websites, even if you're not using a device or you don't anticipate pursuing funding from a particular vendor, some of the big name companies have some really nice tools available on their website, where you can download the mandatory forms in your state.
If you're using Medicaid as a funding agency, either as your primary or secondary funding agency, you can go on a lot of the, um, big DME vendor, like durable medical equipment, which is what covers speech generating devices. You can go on their websites, [00:19:00] put in your state, put in your funding agency and it'll spit out the forms so that, you know, oh, I've got to tell the family that they are going to need a prescription from their physician.
And I can see in the documentation that in order for the physician to do that, I have to have my report and give a copy to the family so that they can give a copy to the physician. Um, and then, you know, there's also the piece of talking to other people in your region because the funding, the third-party funding, uh, requirements are, we'll talk more about this later.
A lot of them trickled down from the Medicare guidelines, uh, but, but there is a lot of variation by regions. And so it's also helpful if you're able to make connections with other people who are doing AAC assessments for funding in your area to find out like, oh, you know what? This reviewer is kind of a stickler about X, Y, Z.
I've found like, youknow, this might be helpful. So I hope that answered your question
[00:19:55] Kate Grandbois: It did answer my question. I just, I think it's just an [00:20:00] important, it's a dicey when you're doing this for the first time, it can be really confusing to have to consider your funding source, but also make sure it doesn't influence your clinical decision-making.
Cause it's, it's, it's very clear once you've been doing it for a long time. I think that was, that was the, that was the main point that I was making. Um, and you know, the funding sources always something. As you just mentioned something that you need to consider when you're writing a documentation, but not all funding sources are created equal either.
There are so many different kinds of funding sources out there.
[00:20:32] Amy Wonkka: There are there, I mean, there are a number of different funding sources and some funding sources don't require an assessment at all. Uh, and we'll this, this gets back to Kate's story, I guess earlier, you know, if, if your funding, if you're not writing an evaluation for funding, should you still document the process?
Um, yes, you should.
[00:20:50] Kate Grandbois: You should. Because of your code of ethics. Yes. The answer is yes. In case anybody's having a question about that. I
[00:20:57] Amy Wonkka: see. We've got, we've got something in the chat. [00:21:00]
[00:21:01] Kate Grandbois: What is it? Oh, I can't see it. What does it say? Yes. Oh yes. Yes. I agree.
[00:21:09] Amy Wonkka: We agree with you. Yeah. So, so we, we definitely want to document it, but if you're documenting for a third-party key medical source, you're documenting medical necessity.
So this gets back to kind of that earlier piece, know what your funding source is, when you're writing your assessment and when you're conducting your assessment, because it helps frame what you pay the most attention to. So if you are writing a funding, um, request for Medicaid or for private health insurance, you're going to want to focus on all of those components that demonstrate a medical necessity.
If you're in an educational environment, it's likely that if you're writing for something that may be funded through a child's district, you're writing about educational necessity. [00:22:00] Um, if you're not required to write a report for any entity, you're really just writing to document your services back to connecting back to the ASHA code of ethics.
You're writing to the document your services, you're writing to make sure that all of the stakeholders are on the same page as far as this process gathering the information, identifying the problem, and then the process through which you guys have tried different solutions and kind of sorting through how, how your client did with those different options and why you're making the recommendation that you’re making.
[00:22:32] Kate Grandbois: And then dealing with the complex and very daunting task of understanding Medicare and Medicaid. This is something that's still, I have the, our state guidelines saved on my h-, my hard drive. I was actually looking for them today. I can't find them, but it's a very long and intimidating document. And it is something that when you're documenting for funding, you can't really gloss over it because you're, you'll get rejected. You will get denied. Those are guidelines that [00:23:00] you really need to know.
[00:23:02] Amy Wonkka: I think it's helpful for people who might be listening, who maybe have only done a few reports for funding, or haven't maybe done a report for funding yet. And you're feeling like this is really intimidating. You also can check all of the boxes.
You can include all of the required material and you can still get a rejection.
[00:23:20] Kate Grandbois: Happens to me, happens to me once a year.
[00:23:22] Amy Wonkka: So that's something else to be aware of. I mean, I think that I could have a whole separate conversation about our health care system and how that works and my feelings about that, but
Kate Grandbois:Tamp it down, tamp it down.
Amy Wonkka: But I feel like, you know, in, in some third party funding agencies do seem to have a mandate to perhaps just reject everything that comes in at the first pass. Uh, so you also need to be in a position to feel confident and empowered that you've conducted a comprehensive assessment and you're prepared to move forward with an appeals process.
If that ends up being what's necessary for you to [00:24:00] serve your clients. Just one more thing. I'm just looking at my notes here. Um, so one thing to be aware of is that when we are submitting for third party medical necessity funding, there is a specific order in which the clients' different funding agencies will be kind of assessed. So if you have a client who has Medicaid and they also have a private insurance that that report and request for funding is first going to go to their private insurance and their private insurance, if they accept it, will be the one that funds the device. If they deny it, then it will go to Medicaid.
But if you have somebody who, you know, that the AAC device, isn't a covered benefit under their private insurance. And you know that Medicaid is the entity that's going to fund the device. You still have to go through the process and submit the information. For it to go and be [00:25:00] denied, um, by their, by their private insurance, in order for it to bounce to Medicaid, Medicaid, won't pick it up unless it's already been denied by a private insurance company, if somebody has private insurance.
And I saw another question in the chat, are tablets considered durable medical equipment by Medicare. That's a really good question.
[00:25:21] Kate Grandbois: That's a great question. Go ahead. You take it.
[00:25:25] Amy Wonkka: I have never written a Medicare, which is for people who are retired. I've never written a Medicare funding. I have done funding for Medicaid, and that is a state, um, administered program. It follows for the most part, Medicaid. It's something that people can be eligible for due to disability, um, or due to income. And so Medicaid guidelines are very similar to the Medicare guidelines and medic, but Medicaid is managed at the state level. So in our state, I [00:26:00] believe they are covered. Isn't that correct?
Um,
[00:26:03] Kate Grandbois: I guess, and I have a story about that in the moment.
Amy Wonkka: Kate has the best stories,
Kate Grandbois: but I've made so many mistakes and I don't mind sharing them, but go on.
Amy Wonkka: Everybody's made mistakes there.
Kate Grandbois: That's how we learn.
[00:26:15] Amy Wonkka: So I would say to you, if you're curious, if it is covered under Medicaid in your state? I would, I would just take to the Google machine, um, and search terms like Medicaid, durable medical equipment, um, iPad AAC, and, and see what your state guidelines are.
[00:26:35] Kate Grandbois: Yeah. And I, I have another recommendation and Amy, you might agree with me and you might not, um, a lot of vendors have the dedicated tablets, so I'm not sure if this individual is talking about an open tablet or a dedicated tablet. So there are some, sorry, what
[00:26:50] Amy Wonkka: do you want toexplain the difference between those two things?
[00:26:52] Kate Grandbois: Yes, I can explain the difference between these two things. So an open tablet or an open eye, an open device is one that is, [00:27:00] you can run additional apps. Basically. It's not, you're not locked into having just one program running and there's a closed device or a closed tablet. And that tablet has it locked in so that it is beyond guided access.
It is the only, the only software that you can run on that plat on that closed system is the communication software, the vendors to meet Medicaid guidelines, the vendors, some vendors will sell dedicated iPads or dedicated ta-. I've never seen anything other than an iPad. So I'm just going to say iPad, not tablet, um, where you can pay an additional fee to have it unlocked once funding has come through.
Um, so if you're interested in pursuing a dedicated tablet or a dedicated iPad, another option would be to, um, go to a vendor. There are a couple of vendors who sell them and their funding department should be able to give you some guidance about whether or not at least my experience with funding departments is that they have someone who's familiar with where you are with your region, with [00:28:00] what's, with what's available to you in your state.
So that's another resource that you can use, but anyway, going on, Amy, was there anything else that you wanted to say about, um, this, these components of funding?
[00:28:14] Amy Wonkka: No, but I'm just seeing in the chat that we have somebody saying, talk to me tech is one of those companies that does a dedicated iPad device. Um, and there are a number of other companies, a number of other vendors that do that too.
So thank you for sharing that Emily
[00:28:29] Kate Grandbois: and in the show notes. Um, and, and when we post this webinar up on YouTube, we can also put some links to other companies that you might just be interested in browsing. We have no relationships with any of these companies. It's completely unethical for us to have any relationships or recommend devices one over the other, but we will list a couple of references and resources where people can do a little bit of self explore and learning.
Um, in terms of, um, conditions being met for Medicare speech generating devices, any Amy, I don't know if you have anything else you want to say about that before I [00:29:00] tell my story.
[00:29:01] Amy Wonkka: Yeah, sure. I'll do the boring stuff you can do the fun stories. Um, so we were going to just direct you all to the ASHA guidance.
That's linked in this slide, if you haven't already checked it out. ASHA does a great job here outlining the key components that you want to include in your assessment, according to the Medicare guidelines. So some of those key components include a description of the person's current communication impairment, and they want information across multiple parameters, such as the severity of their impairment, um, their cognitive status, their communication diagnosis, their medical diagnosis, et cetera.
Uh, they want detailed information about the person's daily communication needs and whether those needs could be met in an alternative way, such as via natural communication, which they're using to cover speech, writing, American sign language, and other options that have been considered and ruled out. So this is [00:30:00] another thing just to point out.
When you're writing for third party funding, there are a lot of times that you need to be explicit in saying, we thought about this and decided that it was, it was not effective for these reasons. Um, you don't just want to proceed with recommending, you know, an aided high-tech tool without being very explicit in your funding report, that that's because writing and speech and ASL and all of these other options are not effective for this person to get their needs met.
Um, some of the other components that this ASHA article recommends that you include would be functional communication goals, including something about the device training. So training for, um, the team around how they're going to implement this device once they receive it, information about the person's cognitive and physical abilities, a financial statement like Kate was saying, saying that you as the evaluator do not have a financial [00:31:00] relationship with the vendor whose materials you're recommending, um, a physician notification.
So saying that a copy of the AAC assessment has been provided to the patient's physician. Um, and then a functional benefit statement might need to be included if you're requesting an upgrade of a current speech generating device. So let's say you have a client who has been using device brand X for the last seven years, and the thing won't charge any longer.
Um, it weighs a lot of pounds. The person's carrying it around it's time for an upgrade. Um, in, in that case, you're going to need to make the case to the funding agency, why they should fund an updated device.
[00:31:41] Kate Grandbois: So I have two things to piggyback onto your brilliance. Number one is, um, I will often label that section of my report, the cost analysis, and I put in a table.
This is like a random little tip. My experience is that a lot of times our reports tend to be very long and I am not convinced that they get read word for word. [00:32:00] So when you can put a table in there, especially when you're looking at a cost analysis for a reviewer who wants to see what the cheapest option is, and that you've justified your choice.
Um, that's something that is, is, uh, relatively easy thing to do. Um, the second thing I was going to say was related to your evidence. So going back to something you said earlier in the episode about how you're gearing your documentation for your funding source, where this is in the context of Medicare and Medicaid, which is a medically necessary device.
If you are trying to justify and, and find evidence for why a more expensive tool might be justified for a more emergent learner. I would definitely recommend leaning on your OT, PT, your other team members to also provide evidence. So for example, I will often bring in, um, an OT to write a recommendation about fine motor limitations as to why they can't access a mid tech device.
[00:33:00] Or if you're working with someone who has seating and positioning needs, why some of that equipment might be necessary. There are the documentation process for funding is oftentimes an exercise in evidence and justification. Um, not always, but sometimes. And so leaning on your, um, other other team members can be a really nice way to sort of pepper in a lot of that evidence.
Do you agree?
Amy Wonkka: I totally agree
Kate Grandbois:I love when you agree. So my story, I feel like I have to tell it now because I've, I've, I've teased it so many times and it's actually not related to any of this. Um, any of these Medicaid, Medicare, um, required pieces of information, but it is related to the Medicaid state guidelines.
So I was in a team meeting where here in Massachusetts. I was in a team meeting and I had just completed an AAC evaluation for a student. And I had forgotten that the student lived in a neighboring state, just over the state line. [00:34:00] And I made a very bold claim in the team meeting in front of the family, with the SLP from the other state at the table.
My bold statement was Medicaid, your insurance is not going to cover an iPad. It is not going to cover an open, open device. It's not going to happen. It's not covered. It was, I was so confident and the SLP, so kindly put me in my place and said, well, actually in this state, and it was like 20 miles away, we can get you an open iPad funded.
And the sweet father looked at me and he said, she really made you look stupid. And I had all the embarrassed feelings. And that was my lesson in making sure that you understand that your state regulations are going to have a significant impact on how you on, on how you write your documentation. That was the end of my story.
[00:34:54] Amy Wonkka: I think that that was a great story. I think another takeaway from that story is it's it's [00:35:00] okay. It is excessively complex. This process is more difficult than some of us in this room think it should or needs to be. Right.
[00:35:10] Kate Grandbois: For those of you who are listening, Amy's aggressive and pointing at herself,
[00:35:13] Amy Wonkka: I'm gesturing, I'm gesturing and statically.
Yeah. Um, so, you know, I, I would also say if you're, particularly, if you're kind of new to this process, be kind to yourself, it's okay.
[00:35:24] Kate Grandbois: Or if you're not new to your process, you can be kind to yourself.
Amy Wonkka: Yes, we should all just be kinder to ourselves. It's okay.
Kate Grandbois:And, and the nice SLP she corrected me so respectfully and nice.
There was no ego in the room. It was lovely, but moving on. Okay. So let's talk about the AAC documentation in and of itself. We're all pretty familiar with writing three-year evaluations. It's something we get trained on in graduate school. There are, you know, we're somewhat familiar with how it starts, how it stops, what sections you might need to include.
Um, and I think it's important to sort of take a bird's eye view of the AAC [00:36:00] evaluation process and think about everything that is included. Um, and as we've already gone over multiple times, you know, it's just so different from a three, from a regular speech and language evaluation, where you do your testing and you white, you, you write one report and then you’re done.
The AAC world is very different. There is data collection and information gathering, report writing, recommendations. Then there's a trial period. Then there's a trial period, includes additional data collection. Then you have your evaluation, addendum, um, or a trial summary at the end, depending on. And then if you're writing the evaluation for funding, there is a packet submission process thrown in there. This is a very complex process. Um, and I, another piece of this linear process, that's much more complex than the evaluations that we're used to writing that Amy and I feel really strongly about is an implementation plan at the end of your evaluation. [00:37:00] So let's say you've gone through an evaluation.
You've done your initial eval you've conducted a trial or, um, written an evaluation addendum. You may or may not have gotten funding. If you got rejected, you've gone through an appeals process where you've gathered additional information and written additional documentation, and it's finally all settled, settled.
Then you have the device. The question then becomes is the evaluation completely over. I will say it shouldn't be, there is an extension of that evaluation process where it's so important to write either consider implementation and training, or if you have the time and the resources writing an implementation plan, creating some additional documentation that extends beyond the evaluation to make sure that the device that you've chosen is being implemented in the, in, in all considered environments properly.
Um, and, um, this is, you know, that entire process is really going to [00:38:00] shape all the different pieces of information that you put into your assessment.
[00:38:05] Amy Wonkka: You might find you're focusing on really specific details, particularly for medically related, um, funding requests and being complete in reporting these qualitative and quantitative data points.
So numbers and feelings and describers, um, is really essential and writing a successfully funded report. Uh, but what you might find is, you know, when you have your report writing glasses on, you might find yourself focusing on these details and thinking, you know what, this really doesn't make for a very person centered process.
Right. And we feel strongly, and we talk a lot on this podcast about the importance of a person centered process for our assessments and our intervention. So how do you reconcile those two things? Right. Um, I think that keeping the distinction between the information that [00:39:00] you need in order for your report and your funding and being aware that that alone is probably not enough information to also be conducting a comprehensive person centered assessment, where you're taking into account multiple stakeholders and environments, uh, and in for me.
Hey, this is the best way to kind of keep it in mind. You have your things that you're paying attention to, because you're going to be sure to write those things down in your report for funding, and then you have other things that you're still paying attention to because they're vital and an essential part of the assessment process.
And that information is probably better captured in some of those pieces that Kate was talking about. Um, in your, you know, maybe you're writing a summary of your trial of the different devices, or maybe you're going to reflect some of that information in your implementation plan documentation. Uh, but just because it's not required by the funding source to gather [00:40:00] information about what's important and meaningful for your client and their family, um, does not mean that those aren't incredibly important pieces to be doing as part of your assessment.
[00:40:10] Kate Grandbois: And I have to make a quick plug here. I'm totally interrupting you for something that you said that we've said a million times on this podcast, but it's worth saying again, qualitative data is still data. It's still critical to include all the feelings, anecdotes, things that you, things that you've seen, things that you've heard. Data doesn't have to just be a numbered data, can be a descriptor and a wonderful well-rounded report will include both of those elements and shameless plug. We have a SLP masterclass coming up on nothing but data collection, because data is so important and it shouldn't be your enemy. It shouldn't even be your frenemy.
There are ways to make that process a lot easier. And I think that's a critical piece of an AAC evaluation because as we will talk [00:41:00] about, they are data-driven decisions, but that doesn't necessarily just mean pluses and minuses on a sticky note.
[00:41:06] Amy Wonkka: Yeah. And it's really, I mean, I think, especially when we're thinking about AAC assessments, it really shouldn't be, right.
If we're just paying attention to the quantitative data, the numbers data, we're missing a big piece of the story, that's important for that decision-making process. But I think that what's important to know and just keep in mind, is that what you'll probably find, particularly if you're writing a report for a more stringent, um, usually like medically oriented funding source at, you're you're not going to emphasize that information. There may be some information that you don't even include in your assessment write up, because that's not what the funder is looking for. You're going to emphasize the components that they require and are paying attention to, but that other information is going to be part of your decision-making process and [00:42:00] part of your intervention.
[00:42:03] Kate Grandbois: And to piggyback on that and to harp back a little bit to something I said before, in terms of what you choose to include. Oh, great way to include data is tables and graphs, and to show progress, to show, to measure, try and measure some of those softer components provide rating scales to family members, to caregivers, to the client, you know, collect all of that information to really use your data, to make sure that it's still a client and person centered process was my, my last plug on the, on the data soapbox.
And I'm done. I swear. Um, okay. So let's think about the evaluation document itself. So funny enough while Amy and I were writing this evaluation while we were writing this presentation, we write our evals differently, go figure, and she trained me and we work together all the time, all the time. And so I think it's [00:43:00] okay to sort of think about these documents as living things that are, that can be slightly different.
And there are common denominators that we'll go through that will make an AAC document, an AAC evaluation document, a comprehensive document, but that there's no cookie cutter. There's no, there's no boiler plate way to go about doing these. Um,
[00:43:22] Amy Wonkka: we do this for folks who are curious how we, how we interrupt each other a little less than normal.
Um, so I think another thing just to be aware of is that a lot of those vendors, a lot of the companies that do, um, sell AAC devices often will have example reports on their website. And that could be helpful if you're somebody who doesn't even have a frame of reference. Like I am, I'm a learn by doing and watching person.
And so if you're a person like that, it might be helpful to just go onto some of those websites. Look for some example reports and just try and build a picture in your [00:44:00] mind about what it might even look like, how much detail you might include, and then you'll get your individual variation. Like I can.
[00:44:08] Kate Grandbois: Yes, and lots of individual variation as it turns out, which is totally fine. Um, so, you know, as we've talked about before, in terms of going through this process, your first exercise is you're collecting all the, you're aggregating all the information you're conducting interviews. You're sitting with your client, your student, you're going through a framework.
If you use a framework like the SETT framework or the Pesico framework, um, and some of the information that you collect will be specific to AAC. Some of the information you collect will, you'll be a little bit more familiar with because you've seen it in other speech and language, um, evaluations. I think what, what, one thing I hear from my mentees very often is that writing these assessments is a vast abyss don't get, and don't get lost because you're collecting so much information.
Um, and when we were doing this, [00:45:00] um, when we were writing. Presentation. I did a little bit of research and found this really, really, really interesting article that I, if you feel like being a nerd and going and doing some unnecessary reading, um, it's written by Slawson and Shaughnassey in 2005, and we have the reference in the show notes and at the end of these, um, And it's about, uh, it's a framework that you can use to extract the most meaningful pieces of information to decide what to include in a report and what not to include in a report.
And it has a cute little acronym. That's very handy to remember: poems P O E M S, which stands for patient oriented evidence that matters. So for me, this is a really wonderful way to think about. What out of all the information that you've collected, which pieces are the most [00:46:00] relevant to the information that you need to document.
So, in other words, when you are going to write these reports, you don't need to include every single thing that happened. Every single thing that you see, you do need to include the pieces that have a significant impact on your clinical decision-making or pieces that are relevant specifically to, to, um, your client or student that are directly related to other aspects of AAC, such as implementation. Um, another piece about documentation is that it is going to be influenced a lot by your workplace norms. And as we will talk about, there are some common denominators that make it good practice. And as I mentioned, Amy and I, Amy trained me and our documentation is different and we work in two different environments and that can have a big impact.
So someone who works in the school, their AAC evaluation will look totally different than an evaluation that's conducted in a hospital. [00:47:00] But hopefully both sets of practitioners have included the ethical, unnecessary information and poems, if you will, um, that will make it a comprehensive assessment. Um, So some sections that you might, but not always, we'll put in an AAC assessment that are similar, that are similar to what you'd see in a speech and language assessment might be medical history, developmental history, educational history, behavioral status, and testing procedures.
Um, this is an example of something that Amy and I do differently. So she does not include a behavioral status section in her evaluations. I do, because it tends to be a component of, of my clients and students that has a significant impact on my clinical decision-making. Um, unless, unless, let me see here.
I've lost.
[00:47:57] Amy Wonkka: Put that in there. I think that I was method. So saying that [00:48:00] if something, did you mess with my notes?,you know, a little bit of highlighted in yellow, so you would notice me
[00:48:04] Kate Grandbois: see no yellow it's okay. I'll forgive it.
[00:48:08] Amy Wonkka: Thanks. Um, so, so Kate's to Kate's point, you're not including something that's not relevant for your client, unless it's something that's required by your funding source.
So just reflecting back on kind of what we were saying earlier. You know, you may have a client for whom oral speech is not an option, and it's something that they're not using at all, and it's not functional for them. Um, but you don't want to omit that information because your funding source may require a statement about that.
So even though that component might not be relevant for your client per se, you're including it because it's required by your funding source. Similarly, the behavioral status, excuse me, component, you know, that Kate's including if that were required by my funding source, I would be sure to put something in [00:49:00] there just saying behavioral status, no concerns or something like that.
Just documenting that you've checked all of those boxes that your third-party funding agency has determined is required for their funding.
[00:49:11] Kate Grandbois: here, here. That was an excellent idea. Green light to mess with my notes forever. Not that you didn't already know that. Um, okay. So sections similar, but different to an AAC, to a speech and language evaluation, um, our receptive language status, expressive language status, and speech status.
So when you ask yourself, why are these included? Well, it should be sort of obvious. These are fundamental pieces of information that presumably drove your decision to conduct an AAC evaluation in terms of language, communication, and, um, minimal or, or less than functional speech. You should always, always, always include this information and they are required by Medicare's my Medicare standards, [00:50:00] according to your notes and my notes, Amy, sorry,
[00:50:03] Amy Wonkka: I didn’t make those yellow.
I just put them in there. I'm noticing them. Uh, no, with that, it's just that most third party funding agencies do kind of follow these Medicare guidelines. So back to that slide that we cited earlier and encouraging you to go check out that link on ASHA's website, ASHA does a great job kind of picking through those different components that all sort of trickled down from those Medicare guidelines.
Um, so that is going to lead you you'd certainly want to check out the actual guidelines of your actual funding source. Um, but reading through those components gives you a really nice picture of kind of what the most robust requirements might look like.
[00:50:48] Kate Grandbois: And I think it's also good to consider, you know, your funding source is going to dictate what you may or may not include in these, but they, these also may, when you write them, be different than what you're [00:51:00] used to writing in a typical speech and language evaluation.
So they might be less in-depth. Um, they might be an overall summary or a snapshot instead of a detailed analysis of what's happening. It may depend on a variety of variables. You may or may not include standardized test scores or other criteria and referenced measures. And I think as Amy said, at the end of the day, you have to include.
Your POEM, you have to include your patient oriented evidence that matters, and you have to include information that is required by your, the funding source.
[00:51:33] Amy Wonkka: And just one more piece about, sorry, standardized assessments, but if you're using a standardized assessment in your administering it and non-standardized manner, um, or you're administering it on somebody who is not represented by the groups that the test, um, creator used in their normative sample, you probably don't want to report standardized scores.
Um, but you can report [00:52:00] overall their performance in the assessment.
[00:52:00] Kate Grandbois: And just a, another shameless plug. We have two courses on assessments and reporting accommodations to standardized tests and the uses of standardized tests and norm reference tests, um, in our library. So if you have more questions about that, you can go check that out.
Um, Amy, tell us about sections unique to AAC evaluation.
[00:52:21] Amy Wonkka: So sections, unique to an AAC evaluation, um, something that you typically don't report in a speech and language evaluation, a standard speech and language evaluation would be things like your client's sensory and motor status, which are linked to their ability to access, um, an aided system.
Similarly, their hearing and vision status. Again, that's connected to their ability to access the system. Um, you, um, may include information about their AAC or more broad assistive tech history. What they've tried, what has worked, what didn't any information about why those things did or didn't work. Um, you're going to be [00:53:00] including data on performance with an AAC tool and or related strategies and kind of what happened with that.
Um, you're also going to need to, if you're making a tool recommendation, you're going to need to provide vendor information. So a sales company that sells that tool. Um, what does the family or the funding agency need to purchase, if anything, and where can they obtain it? And if you're making recommendations about a tool and that tool requires additional peripheral things like, uh, a key guard or an extra battery, a mounting system, you also want to include the request for all of those components as part of your AAC assessment.
So you also want to include trial information or follow up recommendations. We've talked a bit about trials. Um, and that will look different in part, based on your funding agency in part, based on your unique client variables. Um, but generally good practice is that [00:54:00] you are trying a couple of different things.
You're not just saying, well, I picked this one thing and it looked all right, so that's what we're going with. Um, because we don't just want to pick the tool that might work. We ideally want to pick the tool that works best, and that means works best for our client. That means works best for their family and caregivers.
Uh, that means works best across multiple environments, not just your outpatient therapy room or your therapy room at a school or, you know, wherever you're providing your services, we want. And, and a lot of funding sources. I do feel like this is a bit of a change in the last, I don't know, like 10 or so years.
A lot of the funding sources are really asking for data across multiple environments, which on the one hand as the evaluator can make it a bit challenging. Um, I think it's also nice because you're looking at this person's ability to actually access this tool in, in their broader world. We've got a question here.
[00:55:00] Does Medicaid have, uh, sorry, went away, have a requirement for how long a trial must be. That's going to be specific to your funding source and to make it even more complicated. Some places require that you have a funded trial, so you will need to write your assessment, make a recommendation that you try a tool that is then funded by that third-party funding agency.
And then you do an adenda where you write additional information and send it in to request a purchase. Kate, did you have more to add there?
[00:55:36] Kate Grandbois: No, I was always under the impression that insurance trials, but, whether they're funded or not have a limit. So they're generally as a very loose guideline, don't quote me, four to six weeks.
Um, and that is, that can differ a lot based on, and I was going to talk about this on the next slide. When we start talking about trials a little bit in more detail, um, but they will have a [00:56:00] time limit and you are often bound to whatever their rules are, and you have to know what they are. This also requires a lot of really good communication with the family because you're accessing their insurance benefits and you need to make sure that they are also aware of their insurance benefits.
Um, and depending on your workplace setting, you may or may not have other staff who can. Facilitate that communication, um, in terms of an insurance, an insurance liaison, or a social worker, or somebody who is helping to explain what their benefits are, because this can be a very complicated thing and it's individualized for every, every client.
Um, but anyway, so, go on
[00:56:40] Amy Wonkka: I think just one more point to that. I think also some of the vendors can be very helpful because they do have a funding department. Um, I know when I first started doing these assessments and even now I will just call the companies and say, Hey, can you, can you help me out with this?
Sometimes they can. Sometimes they [00:57:00] can't. Uh, but the very least if they don't know the answer, they often have a better idea of like who I might be able to call to find the answer. Um, so being able to reach out to the company that you're thinking about using for your trial or, you know, that's a company that you haven't established a relationship with their vendor, they can potentially help you quite a bit.
Um, so you're going to do a trial. You're going to consider and try a couple of different tools. Uh, many places require a cost analysis. So we are, when Kate mentioned the Peisco framework, um, that's a framework out of children's hospital. Um, John Costello. Anyway, I don't know if he did it while he was at,
Hey John, thank you for your framework. Um, so in there they kind of outlined that, you know, we, our primary stakeholder really is our client, but there are other stakeholders, right? So we're [00:58:00] also, um, we, we are required by most funding agencies to demonstrate that we're picking the most cost-effective options that meets our client's needs.
So you may. You know, try three different tools and the data might show that your client's performance with two of them is similar. If one is substantially cheaper, the funding agency is going to want to go with that substantially cheaper option. Um,
[00:58:26] Kate Grandbois: and then the last, I just want to point out the last bullet here, the statement of financial independence.
This is something that really should be included at the end of every single AAC evaluation or a set of recommendations that you make for ethical reasons. So statement usually goes something like this: Evaluator has no financial relationships with any of the products or vendors mentioned or something along those lines.
Um, and this is, again, going back, we're going to get into, we have found a great article about AAC, evaluations and ethics that we're going to go through, uh, towards the end of the, um, presentation. Um, but [00:59:00] having a statement of financial independence is definitely unique across pretty much any other type of documentation that we tend to do as SLPs and something that is a critical and it's one sentence, but really does need to be, um, included in your assessment.
Um, you also said something a second ago, Amy that I wanted to go back to that's related to the tool trial and how, um, funding sources are now, um, requiring data be collected in more than one environment here in Massachusetts. If you don't submit that data for the home environment and the community environment.
Basically not even going to get reviewed from what I understand. And don't quote me, that's just like the flavor of what happens around here. Um, but I wanted to talk about the importance of that and why it's so important to take data qualitative and quantitative in different environments. Um, and that is because it's one of the best things that you can [01:00:00] do to prevent whatever you recommend from being abandoned or becoming an expensive paperweight.
The trial is really an opportunity for the, for the AAC user family members, caregivers, stakeholders, to get their feet wet, try it out, take it for a test drive, work out the kinks. Uh, I can see that you have words in your mouth saying that
[01:00:24] Amy Wonkka: I do, my body has all the words. Um, so it's also a chance for us to really refine that feature matching process.
Right? We talk a lot in AAC about the feature matching, our second installment, I guess, of the series or what have you was about feature matching and feature matching is really thinking about what are the different features that the AAC device needs to have for my clients? What are the features that would be nice to have for my client?
And what are the features that really kind of don't matter either way. One of the best ways to figure that out is to try a [01:01:00] few different things and they don't all have to be tried for the same extended period of time. Um, but to just try it a couple of times, I write what would some symbols on a piece of paperwork would, um, texting on a phone work, would this specific symbol vocabulary set work?
What about this one? Um, what about if the pictures are this big? Do they really need photographs? All of those. Components are something that you and your client and their stakeholders figure out through this trial process, the route through the trial process, you can come together and say, geez, these are the features that are really important.
So then when you come to do your documentation, You can have data that shows. Yes. In fact, these features are really important and that's why we're making this recommendation. Um, we see in the chat, somebody saying, Kristen saying, I like to meet with stakeholders and write three goals for the trial. I think that's a factor.
Fabulous [01:02:00] idea.
[01:02:00] Kate Grandbois: That's wonderful. Good job. Yeah. I love that idea. What I was going to say, um, was just clarifying a little bit of language. So believe it or not. I had a meeting with my, with one of my mentees today. She's getting ready to do her first Medicaid funded assessment. And the whole time we were having this conversation, she kept using the word.
Okay. So when we choose things for the trial and when we choose this for the trial, and then I was talking about the trial and as it turned out, we were talking about two different things. So I want to make sure that we're being specific. When we say, when we are talking about a tool trial, we are talking about the period of time.
After the initial assessment has been completed. So sometimes people will say, oh, I will try. I'm going to trial the device during that initial assessment where you put three or four or five tools in front of your student or client and work out the kinks and try and come to a final recommendation when that's, you could also use the word trial for that.
But when we are talking about a [01:03:00] funded trial or a trial with a minimum amount of, of weeks or a time limit, um, that is a period of time after the initial assessment, after you've made your recommendations. And you're setting aside this time to really try out the tool or trial the tool, collect data in your multiple environments.
And, and, you know, have that period of time will be shaped by your funding source. Um, but I think it's just important to distinguish between the two, because I had a whole hour long conversation with someone today and turned out we were using the word wrong, or differently,
[01:03:33] Amy Wonkka: not wrong, just differently not wrong just different last thing, before we transition off of this slide, just to reference back to that ASHA article, um, they, they list the different CPT codes, which are the billing codes for speech generating devices.
And I feel like reviewing that list can be really helpful for speech language pathologists who are conducting AAC assessments, because it can help us to consider. And again, document our consideration of those less [01:04:00] expensive options when we're writing our reports for funding. So this is going to allow us to be sure that we have ruled out least costly, equally effective alternatives.
Um, and we need to rule these options out specifically because that's a, that's a great reason for third-party funders to deny the funding requests. So if you can go through, you can go through your unaided options, like oral speech, um, but you can also go through some of those different CPT codes. Like we've ruled out something with digitized speech, less than 10 seconds because XYZ, my client can't change the overlays independently, or, you know, this doesn't allow access to enough robust vocabulary.
So referencing that list, if you're not super familiar with all the options that are out there can help you think through what you might try with your client, but also make sure you're documenting the things that you thought about, but didn't choose for specific reasons.
[01:04:56] Kate Grandbois: And in terms of addressing, you know, these two additional points are, [01:05:00] are tool trials required and are they best practice?
Um, I would say that they're required based on your funding source. So your funding source is going to dictate whether or not you have to do a trial. And I have a little story about that, that I'm, I'm full of stories today. Um, and, and the, um, the, to answer the question as to whether or not they're best practice, I think yes, doing a data-driven trial is definitely a common denominator of a comprehensive, um, AAC evaluation. Um, and it's because it's really the opportunity that you have to show that you're not making this choice in a vacuum. You're not just deciding things arbitrarily, you're giving your client or the AAC user an opportunity to experience the tool before committing to it. You're giving them their caregiver as an opportunity to weigh in or relay their preferences.
Make sure that the tool that you've been reco, that you've recommended is in line with [01:06:00] their values. Um, and it also gives you an opportunity to tweak things. It gives you an opportunity to consider your implementation plan and your teaching strategy. Um, and as we've already mentioned, AAC evaluations without a trial can result in risk of abandoning the tool.
Um, so this, this is how I'm going to lead into my story here. So AAC trials are best practice. We've already covered that. And I had a situation recently. Where I had evaluated a student who was an emergent learner, um, vocabulary size was maybe 10 single words. We trialed a high-tech tool over four sessions.
And over the course of those four sessions, this individual started producing four, five and six word phrases, phrases. Okay. So this is a Y it was a wild situation. Um, they were using words they had never used before. After one model, one of the teachers was crying. This was like the moment that you live for [01:07:00] working in this, working in this field.
And I knew the classroom staff really well. They were really familiar with all the tools that I had shown the student. Um, Having participated in the evaluation from the get-go they had observed, they had participated in interviews. They were onboard. They were so excited. The students showed really strong preference for one tool over another.
And by really strong preference. I mean, every time I showed them the other app, they got very frustrated and shut it down and opened the other one and started communicating. So there was no, there was no question in my mind that the client, the student had demonstrated a strong preference for one tool over the other.
Um, the family already owned an iPad and they had already expressed that they were not interested in going through insurance and they did not want to go through another funding source such as their school district. They wanted to pay for a privately, um, whatever I recommended for whatever reason, [01:08:00] um, they had been verbally informed of how successful the evaluation was and they were so excited that the, overnight, without even any documentation, the parent woke up to an email that the parent had downloaded the app and they were really familiar with it.
And the student had sort of chosen it for themselves and had started playing with it. And it was all awesome. Um, On top of this, the evaluation took place during a time of year where the app that I was recommending was going on sale for half off, like the next day. So I had so much evidence that this tool was the right fit and the student had shown a strong preference for the application.
The team was on board. The family was on board. The communication partners were on board. And I didn't want to delay access to the system just because of this rule that I had to do a trial. So I went back and forth and I hemmed and hawed, and I decided not to do a trial. And then I totally freaked out. I totally panicked.
I called Amy and I said, I didn't know what to do. I felt [01:09:00] like I had made a horrible mistake. And Amy, Amy justified my choices with this really beautiful zoom out analogy. And I wonder if you would, I wonder if you would do that for us here?
[01:09:09] Amy Wonkka: I don't even remember what I said to you, buddy. Um, but I think that what I would have said to you was, you know, what, what information do you have so far.
And what information do you think that you would get that would change your opinion through a trial?
[01:09:25] Kate Grandbois: Th there was nothing. Right, but it was also the zoom out was the, you know, looking at the direct, the preferences of the student, looking at their performance of the student and then looking, you know, I'm making this gesture with my hands, sort of like getting bigger and bigger and looking at all of the different communication partners zooming out.
Right. We had done that through the trial. So I guess I tell that story, I mean, through trial, through the assessment. Um, and I tell that story because, I think that's an exception, not the rule, but it does happen. And you [01:10:00] really do need to consider individual situ, individual circumstances when you're conducting an AAC assessment.
[01:10:07] Amy Wonkka: And I think another couple of key points there are that you conducted the assessment with multiple stakeholders and multiple stakeholders were involved. I mean, we met way back in the day when we both worked outpatient and outpatient assessments, I feel like have an additional layer of challenge because you are often in an environment that's removed from your client's customary environment and that, and you have like productivity requirements, all of these other things on top of that, then make it really challenging to get input from multiple stakeholders.
Um, So I think, you know, you're doing the trial, you may need to do a trial just because you need to do a trial for your funding source. And that was not the case in your example. Um, but you're also doing it to make sure you understand the features that are important and make sure that you have the best fit.
Um, so I think those are all just things, things to keep in mind that unless it's [01:11:00] a rule from your funding source, it doesn't have to be a hard and fast rule if you really have adequate data from the assessment,
[01:11:06] Kate Grandbois: but it is best practice. I think that's the, that was, that was my takeaway. Okay. So moving on.
So we had mentioned this already. One of the most difficult pieces of this process is learning what to write down in your document as you've collected so much data. And going back to this concept of poems, poems is your friend patient oriented evidence that matters. So some questions that you could ask yourself, you could also read this article.
This is an awesome article, Slawson and Shaughnessy 2005. Does the information change your clinical judgment? Is your recommendation based on this information feasible and does the information focus on outcomes that the patient cares about? So again, looking at all of your information and making sure that you're going through this process as a patient or person focused process, and if it's, if some of it's relevant, some of it's not relevant, um, [01:12:00] like we’re sort of brushing up against time. So I will tell one very quickly quick, this time, this example of should you include tapping? So I'm a student that I was evaluating, had a preference to tap on everything. Tap, tap, tap all day long. And during the evaluation, the student communicated beautifully. And as they were communicating, they tapped quite frequently on the device.
And the mentee I was working with had included all of this information about tapping in the report, but the question was, do we really need to include information about the tapping, if it had no impact on their communication whatsoever, what components of the tapping may or may not impede communication, how would be a barrier to a teaching procedure or process?
Um, so again, just sort of thinking about all of the pieces of information and making sure you only include the pieces that are most relevant to these components of poems, I think is a really great place to start. Yeah. And, and [01:13:00] again, onto data.
[01:13:02] Amy Wonkka: And so to go back to Kate's point about the data and including the essential data, um, one place where you might include that is if you found, you know, what if I put like a 10th of a second dwell time on there, then my client, isn't getting frustrated with all these repetitive activations and they're, they're much more effective as a communicator.
Then you might want to include that information because it becomes a feature back into feature matching. Then you need something that has the option to allow for a 10th of a second, 12 time, or, you know, uh, activate on release or, or any of those other options that may help your client to better physically access the tool.
Um,
[01:13:42] Kate Grandbois: So, this is, I think what, when I mentioned something about data, again, qualitative and quantitative qualitative and quantitative data are both so important. I can't say enough about tables and graphs. It's so hard to analyze data and explain the point of data and the narrative. [01:14:00] Um, so if you have the opportunity to use a table or graph for quantitative data, I'd definitely recommend doing it.
Um, and including anecdotes is really important, too. Did you have anything that you wanted to say there?
Amy Wonkka: I agree with you.
Kate Grandbois: Excellent. Um, and both are critical in the initial assessment process. And again, if you want them, if you're intimidated by data or when to learn more about data, we have three podcast episodes on an and an SLP masterclass on it.
Um, and again, AAC recommendations are data-driven decisions. They're so, so, so important. And it's a critical piece of writing addendums and trial summaries.
[01:14:39] Amy Wonkka: And sometimes you may find if you get a request for funding rejected, if you present your data in a different format that might help because the people who are reading these aren't necessarily people who are conducting AAC assessments themselves.
Um, so you also want to think about the readability of the information that [01:15:00] you're presenting. Um, and I think that's where Kate's love of tables comes in.
[01:15:06] Kate Grandbois: It was a joke. You're the one that loves the tables. Silly goose. Okay. So thinking about the trial and beyond, um, implementation plans, we've already gotten on a little bit of a soapbox about implementation plans, but it's so crucial to consider implementation plans when you're writing your recommendations.
There's nothing more frustrating than seeing or meeting an AAC user who may or may not have a tool prescribed to them that they are not using, because there are some barrier like training or accessibility that is easily overcome. If there is a little bit of thought and time placed into the actual implementation of the tool, um, an implementation plan, Amy taught me about these as usual. There are documents that you can generate that, um, you can give out with the [01:16:00] final evaluation document. It's great to create them as a permanent product in a table if you are so inclined because they allow you to distribute them as permanent products, to different classrooms, to different people on your team, to families, to other places in the community where your client or student may be going regularly.
Um, and then another great thing about implementation plans is they're a great jumping off point to consider the communication partners and the different environments where an individual is going to be using their tool so that you can tweak the implementation plans to best suit those environments. So if you have the bandwidth and you have the resources to write an implementation plan, please consider including them as an extra piece at the final piece of your final recommendations in an assessment.
Okay. So. When we were going to be sort of we're at the finish line here because I crossed the finish line for this presentation. And this we've [01:17:00] found two really great articles, um, related to financial relationships and ethics in AAC evals. And we're going to go through one of those articles in detail for our last couple of minutes.
Um, for those of you who are listening, the two articles that we're referring to are Navrosky 2015 and Higdon and hill 2015, both of the references will be in the show notes and on the handout that's available. Um, vendors have financial relationships with your recommendations. And this can be a very complex and tricky situation to be in, particularly because sometimes the vendor representatives are also SLPs and they may offer to come help you with your assessment, which can feel great because you have an extra set of hands.
You have someone on hand who knows the equipment, so you don't have to spend time fumbling to make the eye-gaze work or whatever it is, but it's a really critical thing to remember [01:18:00] that the individual, if you do have a vendor in your assessment with you, that person has a financial relationship with your recommendation, that is a sale, and you really need to make sure that there are boundaries and you've established some clear boundaries around your, your clinical recommendations and their opinions or their presence during the assessment.
Um, And again, this article by Higdon and Hill 2015, does this really wonderful job of describing the relationship between financial relationships and your recommendations. Um, you cannot allow financial relationships and or employee policies to influence your clinical decision-making in AAC evaluations.
So again, that's different from letting the funding, the fund, information about funding dictate your documentation. We're talking about having those factors influence your, um, the feature matching process and your clinical decision-making. [01:19:00] So to go through this, um, a little bit in a little bit more detail, this article by Higdon and Hill in 2015 has this really, really wonderful list of rules.
And they're literally rule one rule two, and we are going to go through each one of them. This article, if you'd have not read it, it's a must read. Um, again, it's all about ethical considerations for AAC evaluations and the list of rules of commitment, that's what they're called, um, that we really should be going through.
So rule one, be committed to following your professional code of ethics, scope of practice and up policy documents. This is such an infin, is such a fantastic role, but it also implies that we're really intimately familiar with these documents, which a lot of us haven't read in a long time. So if you haven't read them, please go back and read the, your scope of practice documents and your ASHA policy documents.[01:20:00]
That this role also lays out workplace restrictions. Workplace restrictions are real. Caseload, workload, burnout, and burdens are real. Be cognizant of situations where these burdens influenced your recommendations. So if you have a caseload of 140, let's think about how complex these AAC evaluations are, they're incredibly time intensive and they require a lot of attention to detail on aggregating a lot of information from a lot of different sources.
Do you realistically have the time to allocate to a comprehensive AAC evaluations with those workplace restrictions and does that butt you up against a little bit of an ethical issue, again, amazing article to have on hand, especially if you're talking to your administration about any of those workload issues.
There are scope of competence issues within AAC. So just because you have experience with one aspect of AAC does not mean that you can or should do all AAC. I'm going to use myself as an example. I was originally trained in a [01:21:00] hospital and had exposure to some various different kinds of access types, complex bodies.
I haven't done that in eight to 10 years, so I'm not going to touch it with a 10 foot pole. I have really exclusively worked with one population with direct selection most recently, and that's what I'm going to stick with. So when in doubt, refer out and make sure that you're committed and you're considering your code of ethics and your scope of practice documents before you do these assessments.
Rule two: be committed to conducting a comprehensive AAC evaluation, to gather evidence required for SGD funding. So we view re we reviewed this a little bit in a previous episode, um, but this is again where poems is going to come in. So your patient oriented evidence that matters is really gonna improve your documentation and make sure that you're con you're you're conducting one that's comprehensive and in line with your funding source.
Recommendations are not opinions. Recommendations are [01:22:00] made through a systematic data-driven process. Um, And again, thinking back to your workplace norms, if that if your workplace norms make it difficult for you to, for you to do this, have a conversation with your admin, administrators about the ethical impacts that this have on you, and you should talk openly with them about funding productivity and get creative with examples, um, funding, paperwork, and AAC evaluations are not the same thing.
So again, being cognizant of all of the additional workload that comes with all of these things. Rule three, be committed to a fair and unbiased SGD trial process, independent of the funding source. We've talked about this at length throughout this presentation. A lot of times a trial with the device is funded by insurance, or it comes directly from the vendor, the recommendations coming out of any trial should again be data-driven. Does anybody hear a theme? Data-driven data-driven data-driven trials, data-driven process. Rule four, be committed to [01:23:00] fully informing the client and family of con of the comprehensive range of AAC intervention options. During the evaluations. Remember that story? I told you where this family just paid out of pocket because they were told to do something? Totally a violation of this rule.
We really do need to put our counseling hats on and make sure that we're explaining this process to families, particularly if there is an, if there is a chance that this is going to be something that they're paying for out of pocket, even if it goes through their insurance and they have a deductible, um, you know, they are a consumer and they have the right to be an informed consumer.
And it's our job to make sure that we, that we do that comprehensive. Rule five fully disclosed, potential conflicts of interest regarding financial and non-financial relationships. This is again a huge ethical requirement for all of the reasons that we've talked about. Um, it's often a statement that goes at the end of the report.
That's how you cover that rule. Oh, and I flew through them. That was all the rules. I love that article. And [01:24:00] I think if anybody hasn't read that article, I definitely encourage you to do it. Um, I mean, I definitely encourage you to read it. Um, we've been doing this for, you know, too many years and it was still very eye opening and I think that sort of wraps us up.
Amy, do you have any, are there any questions.
[01:24:19] Amy Wonkka: We don't have any questions in the chat right now, but we do have a whopping four minutes.
[01:24:24] Kate Grandbois: So anybody has, yes, I will. Um, actually submit a question that, um, one of my mentees had asked me to add to, to bring up today. So the question was, can you do a trial on an iPad, even though you want to submit funding for the dedicated device?
Amy Wonkka: What was your answer?
Kate Grandbois: What's your answer. I was going to ask you to answer that you answered it earlier today.
[01:24:49] Amy Wonkka: So I think it really depends on your funding source. It really depends on your funding source. So if you have a funding source that requires a funded rental, then you're going [01:25:00] to need to be sure to do a funded rental.
If as you're talking about, you're looking at a dedicated device, that is exactly the same. So if I am using an iPad in a specific case, with a specific app and it's locked into that app. It's exactly the same product that would be coming as a dedicated device from a vendor. Then it's an analog. And unless you have a requirement for the funding source, I think that you could report your data.
But I'm curious about what you think about this.
[01:25:32] Kate Grandbois: I think that, I think that sounds about, you know, I'm just going to defer to you. I think that, I think that sounds accurate. Um, and in the interest of time, I think we have time for one more question. And there's one other question on here that I think would be a really good question to ask.
What do you do if, um, the family would like to go through insurance for a Medicaid or a private insurance funded eval, but there are not enough [01:26:00] supports in place to collect data in the home or in other, in other parts of the users can be. What should you do? I think that's a really good question.
[01:26:10] Amy Wonkka: Do you want to ask any, answer your question or would you like
[01:26:13] Kate Grandbois: you want me to answer?
So I think that this poses a, a really unique challenge, because not only does, not only is it possible that your funding source is going to require data collected from multiple environments, but from an ethics standpoint, you really do need to make sure you consider additional environments before making a recommendation.
I would, honestly I would get creative. I would, you know, we all have cell phones now. We're all really used to zoom. I would consider maybe a store and forward approach to collecting some data. So if the family has the bandwidth to take some videos of what's happening at home, take some videos of what's happening in the community for you to code that as data later in, in whichever way [01:27:00] you feel is most appropriate.
Um, I would also consider other ways of collecting data like handouts or Google forms. Um, it doesn't necessarily have to be standing there with a clipboard observing everything. So really sort of getting creative with your data collection strategy. And I would imagine that there are some creative ways to do it to, because I mean, again, depending on your funding source, it might be a requirement.
Do you have any additional thoughts about that?
[01:27:27] Amy Wonkka: I think those are great. And the only thing that I would add would be just to think about making sure that you're working with your stakeholders to come up with data collection systems that meet their needs as well as the needs of the funding agencies. So that might be something as simple as filling out a Likert type scale and circling, like this was easier, harder, or in the middle, um, after a couple of different interactions.
[01:27:54] Kate Grandbois: Okay. I agree. Does anyone else have any other questions?
[01:27:55] Amy Wonkka: You've got a question in the chat. Do [01:28:00] you ever recommend something that the parents don't like.
[01:28:03] Kate Grandbois: That's a good question. That's a good question. I have my answer. Do you have your answer?
[01:28:08] Amy Wonkka: Are we going to say them together?
[01:28:10] Kate Grandbois: Ready? 1, 2, 3, no.
[01:28:13] Amy Wonkka: Um, so, and, and the reason for that being parents and guardians, when we're talking about pediatric clients are going to be the communication partner that stays where all of us go away,
[01:28:26] Kate Grandbois: we're all transient.
[01:28:28] Amy Wonkka: But with that, I have had times where perhaps we needed a little bit more support to feel comfortable with a couple of different tools and make, um, make an informed decision. So I think that you also want to be aware of the difference between somebody's initial impression and somebody's impression after they've had a chance to take something, play with it, understand it a little bit better and make a more informed choice, similar to what we're doing.
We were doing a trial and we're trying to identify those features for our feature matching process. You can kind of apply that same [01:29:00] construct with our communication partners across different environments. What are some features that are important for you? You don't like this option because of X, Y, Z.
Okay. That's important information for us.
[01:29:11] Kate Grandbois: Uh, great. Does anyone else have any questions? I can't see the, I can't see the chat, so annoying.
[01:29:15] Amy Wonkka: I can see the chat. There's no more chatting,
[01:29:20] Kate Grandbois: No more chatting. Well, thank you everyone for joining us. This was really fun. Um, I'm I'll shop, stop sharing my screen. Now, if anyone has anything else that they want to add to the conversation, you can feel free to email us anytime info@SLPnerdcast.com. If you are interested in using this webinar or podcast for ASHA CEUs, you can, um, access those through our website, www.slpnerdcast.com. And thank you everyone for joining us. Thanks so much. Thank you so much for joining us in today's episode, as always, you can use this episode for ASHA CEUs.
You can also potentially use this episode for [01:30:00] other credits, depending on the regulations of your governing body. To determine if this episode will count towards professional development in your area of study, please check in with your governing bodies or you can go to our website, www.slpnerdcast.com. All the references and information listed throughout the course of the episodes will be listed in the show notes.
And as always, if you have any questions, please email us at info@slpnerdcast.com. Thank you so much for joining us and we hope to welcome you back here again soon. Another big thank you to our corporate sponsors Vooks who helped to make this episode possible. Our corporate sponsors keep our CEU prices low and our program ad free. Vooks is a library of storybooks with read along texts, designed to improve engagement and reading fluency. Kids can track with the highlighted text and you can pause to go over words and phrases. Join 1 million educators and specialists by trying Vooks for free for sevendays@vooks.com.[01:31:00] .
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