The Role of the Speech-Language Pathologist and Assistive Technology in Life Care Planning

The purpose of a life care plan is to identify the comprehensive and individualized needs of a person as they relate to a disability or chronic illness with relevant associated cost consider­ations. These needs are the operational components of a life care planning process. They should never be compromised or manipulated. The costs assigned to these needs are determined by the geographical consumer rate for the identified services and equipment. The costs can be developed through understanding the range of available funding streams, creative and innova­tive ways of negotiating, available resources, and the cost projection analyses that accompany such planning.

The SLP must be well grounded in the theory of normal development in all ages, in any previ­ous learning or developmental problems affecting the individual, and in the current status of the individual, and must be able to predict future functioning of the individual. Many times SLPs will practice in the treatment of either the pediatric or the adult population. This frequently precludes the SLP from being able to look backward or beyond to make accurate recommendations about future functioning needs.

It is always useful for the SLP, who is consulting in the life care planning process, to be able to actively engage in the clinical treatment of individuals and their families. This enhances the SLP’ credibility, because the SLP should have realistic estimates of current needs and prognostic predictions. However, it is also imperative that the consulting SLP have a fluid understanding of the current literature and research that directly or indirectly impacts the area of communication
sciences and disorders. This includes knowledge of the most current assessment procedures, state- of-the-art assistive technology, trends in pharmacology and medical care, and possible needs in the areas of residential and geriatric care (ASHA, 1993).

The generally accepted national standard for practice in speech-language pathology (communica­tion sciences and disorders) is the American Speech-Language-Hearing Association (ASHA) cer­tificate of clinical competence in speech-language pathology (CCC-SLP). The ASHA CCC-SLP requires a master’s degree in speech-language pathology, completion of a 1-year clinical fellowship, and successful passage of the national examination. For states with licensure (50 for audiology and 47 for speech-language pathology), the legal right to practice will vary with the individual licensing acts. Most licensure laws were modeled after the ASHA CCC standard (ASHA, 1996). Licensure, unlike certification, is mandatory for those states that regulate the practice of audiology and speech-language pathology. In many states, licensure requirements parallel those of ASHA certification. Further, ASHA certification will satisfy many of the requirements of state licensure when you apply for reciprocity. Table 9.1 shows the states with licensure of SLPs and audiologists.

 State Licensure for SLPS and Audiologists

a Does not regulate the profession of speech-language pathology.These individuals may hold additional credentials through their state education agency. Often, the state education agency requirements do not equate to the national standard, requiring only a bachelor’s degree and education certification in a state to practice. Twelve states require school-based audiologists and SLPs to be licensed (Connecticut, Delaware, Hawaii, Kansas, Indiana, Louisiana, Massachusetts, Montana, New Mexico, Ohio, Texas, and Vermont). SLPs with specific interests may hold additional certifications determined by societies and organizations interested in develop­ing credentials to define expertise in a particular area, such as the Rehabilitation Engineering and Assistive Technology Society of North America (also known as RESNA) or the special-interest divisions of ASHA.

Codes of ethics for all organizations in which an individual holds membership must be acknowledged and followed. Ethics is defined as “the study of standards of conduct and moral judgment … and the system or code of morals of a particular profession” (ASHA, 2003). When applied to a field or professional area, such as augmentative communication, or a profession, such as audiology or speech-language pathology, the ethical conduct of practitioners is embodied both in a code (or canons) of ethics and in standards of practice. SLPs and audiologists must comply with the code of ethics for their discipline. The code of ethics for a discipline is typically developed by the professional association serving it. The ASHA code of ethics sets forth the fundamental principles and rules considered essential to the preservation of the highest standards of integrity and ethical conduct to which members of the profession of speech-language pathology and audiol­ogy are bound. All professional activity must be consistent with the code of ethics. The Principle of

 ASHA Special Interest Divisions Language learning and educationNeurophysiology and neurogenic speech and language disordersSpeech science and orofacial disordersHearing and hearing disorders: research and diagnosticsAural rehabilitation and its instrumentationHearing conservation and occupational audiologyAdministration and supervisionAugmentative and alternative communicationSwallowing and swallowing disorders (dysphagia)Communication disorders and sciences in culturally and linguistically diverse populations

Ethics II, Rule B, especially important in the area of assistive technology, states “individuals shall engage in only those aspects of the profession that are within their competence, considering their level of education and training” (ASHA, 2003a).

When funding is available, third-party intermediaries in most instances require the ASHA CCC and licensure. The national certification standards are generally tied to the ASHA CCC for both funding by third-party intermediaries and for service delivery. On the other hand, other certifications in existence, such as the education agency certification, traditionally do not equate to the CCC. If you are not familiar with an individual and his or her credentials, it is wise to contact ASHA and the state licensing board to determine his credentials. It is also important to note that licensing laws usually relate to direct patient assessment and treatment in the state where the service is provided, but do not address review of records or expert testimony. The national certification is a generic certification whereby the individual has met the minimum entry-level requirements across a broad spectrum of knowledge areas in communication sciences and disor­ders. When funding is available, third-party intermediaries use as a guideline the requirements for service delivery established by Medicare and Medicaid (i.e., ASHA CCC-SLP) and, where applicable, a current state license.

SLPs who have the expertise to provide information in their area must also understand and participate in transdisciplinary integrated assessment and treatment models; have knowledge of funding streams and creative funding; be knowledgeable about state and federal policy, laws, and changes in these laws and policies; and be knowledgeable of collaborative sources and how to build them. They must also be able to provide clear, concise, understandable documenta­tion that is written in a defensible but understandable format with functional milestones and goals available. For a complete communication assessment and many of the services related to delivery of care for individuals exhibiting communication and swallowing difficulties described in this post, it is advisable that the consulting SLP hold a doctoral degree with emphasis in the areas of assistive technology.

The competent SLP has received preparation in the following areas, as they relate to human com­munication, swallowing, and development across the life span:

¦     Theories and processes of normal development and aging, including motor, cognitive, social- emotional, and communication

¦     Physiology of speech production and swallowing, including respiration, phonation, articula­tion, resonance, and the vocal/aerodigestive tract

¦     Embryological, genetic factors in development, including the development of craniofacial structures and the nervous system

¦     Anatomic structures, neuroanatomy, and neurophysiology supporting speech, language, hearing, swallowing, and respiration

¦     Organic etiologies of disorders of communication and swallowing

¦     Psychological and psychosocial influences on communication and swallowing

¦     Neurolinguistic, linguistic, cultural, and social influences on communication

¦     Theories of speech perception and production, language development, and cognition

¦     Ethics related to diagnosis, treatment, and professional conduct

Voice Disorders Addressed by the SLP Hyperkinetic (spasmodic dysphonia, essential tremor)Hypokinetic (Parkinson’s disease)Mixed (amyotrophic lateral sclerosis, TBI, multiple sclerosis)Upper motor neuron (UMN) Vocal fold paralysis

¦     Basic computer theory and systems applications, including frequently used software and input and output devices, as they relate to evaluation and treatment of language, cognitive communication, augmentative and alternative communication (AAC), swallowing, voice disorders (see Table 9.3), and central auditory processing disorders

The SLP who is consulting on a life care plan should demonstrate an advanced knowledge and understanding of health care and educational facility practices; the common diseases and condi­tions affecting human communication, swallowing, and development across the life span; and medical, educational, surgical, and behavioral treatment as they relate to communication dis­orders, including knowledge of:

¦     Medical terminology

¦     Physicians’ orders, confidentiality, legal issues in medical practices, and information and data systems management

¦     Elements of the physical examination and vital sign monitors

¦     Medical and laboratory tests and their purposes

¦     Medical record documentation practices

¦     Pharmacologic factors affecting communication and cognitive processes, development, and behavior

¦     AT, AAC approaches, and the range of bioengineering adaptations used in medical settings

¦     Concepts of quality control and risk management

¦    Concepts in medical setting environmental safety (such as universal precautions, proce­dures, and infection control principles; radiation exposure precautions; and the Safe Medical Devices Act)

¦     Team processes

¦     Performance improvement processes

¦    Theories, concepts, and practices in outcomes measures

¦    Theories and concepts related to the impact of psychosocial and spiritual needs and the individual’s cultural values on health care services

¦    Voice and laryngeal health and disorders

¦     Respiratory functions, tracheostomy tubes, and respiratory support requirements

¦    Neuroanatomy, neuropathology, and the neurophysiological support of swallowing, speech, language and related cognitive abilities (Table 9.4), and the effects of diseases and disorders of the nervous system

¦     Concepts in human nutrition and hydration needs and their disorders

¦     Methods and interpretations in neuroimaging and other forms of anatomic imaging

¦     Esophageal, oropharyngeal, laryngeal, and neurologic tumors

¦     Concepts in neuropsychology and psychiatric and psychosocial disorders

¦     Common medical conditions

¦     Educational terminology

¦     Federal mandates related to education

¦     Broad understanding of curricula and literacy

¦     Educational philosophy of state education agencies

¦     Medical and surgical management of communication and swallowing

The SLP should be able to demonstrate advanced skills and abilities in diagnostics, treatment, and service delivery. The SLP should be able to review medical records and conduct succinct clinical case histories and interviews to gather relevant information related to communication and swallowing, and to select and administer appropriate diagnostic tools and procedures and treat­ment for communication and swallowing disorders that are functionally relevant, family centered, culturally sensitive, and theoretically grounded.

Table 9.4 Language versus Cognition

Note: This table lists the areas of language and cognition the SLP assesses and treats.

The SLP should be able to:

¦     Conduct reliable and accurate modified barium swallow procedures following a standard protocol that includes identification of structural abnormalities; swallowing motility dis­orders; presence, time, and etiology of aspiration; and appropriate treatment techniques (posture, maneuvers, bolus modification).

¦     Determine patient management decisions regarding oral/nonoral intake, diet, risk precautions, candidacy for intervention, and treatment strategies.

¦     Select and appropriately apply aided and unaided communication, including both linguistic and nonlinguistic modes and methods.

¦     Locate and access assistive technology (AT), services, and funding sources.

¦    Work effectively with interpreters and translators and use assistive listening devices when needed for patient care.

¦     Communicate findings and treatment plans in a manner that is fitting and consistent with health care facility procedures.

¦     Counsel and educate patients and families and work within family systems to elicit parti­cipation in the treatment plan and work as a member of a health educational care team. (See also Table 9.5 for a description of the types of physical and communication impairments that may need AAC or AT evaluation by a SLP.)

Progressive deteriorating central and peripheral nervous system diseases (Parkinson’s disease, ALS, multiple sclerosis, Guillain-Barre syndrome, dementias, and Alzheimer’s)

The SLP will need to consider all of the following categories, regardless of the age of the indi­vidual, in the development of information for the life care plan: an oral and pharyngeal swallow­ing (dysphagia) assessment to include modified barium swallows, videostroboscopy evaluation, prostodontic intervention, and palatal prostheses; cognitive commu­nication information; auditory processing information to include central auditory processing, augmentative communication assessment information, AT assessment information, voice and vocal information including vid­eostroboscopy, and Botox assessment information; oral peripheral motor information; hearing acuity informa­tion; assistive listening device; and cochlear implant information.

The critical information obtained from a thor­ough communication sciences and disorders assessment must be considered within all the parameters of the life care plan itself. In other words, any and all areas that are impacted by deficits in communication and swal­lowing must be addressed with recommendations, if deemed appropriate by the evaluating SLP. These param­eters include projected evaluation, projected therapeutic modalities, diagnostic testing and educational assess­ment, mobility (including accessories and maintenance of mobility technology), aids for independent functioning, orthotics and prosthetics, home furnishing and acces­sories, pharmacology needs, home/facility care, future medical care, transportation, health and strength mainte­nance, architectural renovations, potential complications, orthopedic equipment needs, vocational/educational planning, AT in the areas of sensory deficits, cognitive challenges, and communication disorders (including
hearing and processing difficulties needing assistive listening devices).

Jenny Craig, the well-known cofounder of weight-loss centers, had a bizarre accident in 1995. She was watching television while sitting on a couch with no headrest. She fell asleep and her head fell forward with her chin on her chest. A loud noise from the TV startled her and her head jerked up, causing the mandible to snap over her maxilla. She had to pry her teeth apart, and began to speak with a lisp as a result of trying to keep her lower teeth from hitting her upper teeth. She immediately saw her dentist, who referred her to a tempo­ral mandibular joint (TMJ) specialist who told her that she had dislocated her jaw. The TMJ specialist recommended she try dental appli­ances, none of which helped. Her speech problem became worse and chronic. She was diagnosed with focal dystonia of the mandible (involuntary muscle contractions that induce abnormal movements and postures caused by the trauma of the sudden jerking of her man­dible). She received Botox injections in her cheeks, which had no beneficial effect on her speech. Three years after the accident, she saw a reconstructive surgeon who specialized in cleft lip and palate and was able to repair some of the damaged muscle tissue that had been caused by the years of abnormal man­dibular movements. In addition, the surgeon was the first person to recommend speech therapy. Craig began working with an SLP 5 days a week, 1 hour per day plus speech exer­cises in between appointments. Although her speech is not the same as it had been before the unusual accident, Craig is thankful she can communicate with people. (Fogle, 2008)

The importance of terminology relative to our communication with other professionals and the general public, as well as the very special needs of international and transdisciplinary communi­cation and development, has become increasingly apparent. In addition to improved consistency in the use of terms, there is the need to carefully examine what meanings the developing jargon may have to other individuals who rely primarily on a dictionary and common sense. Although many people in the field may know what is meant by a given term, others may not share the same meaning. Some terms used by many people in one country may not easily translate into other languages. Even more apparent, with the diversity of people in the world today, care must be exercised to consider multiple interpretations of a term, sometimes affected by the perspective of one’s culture.

Because of the transdisciplinary nature of the medical-legal-clinical world, there are also problems of various disciplines using other jargon to describe essentially the same phenomenon, act, or characteristic. These problems reflect the need for an emerging field like life care planning to develop an internally consistent and logical terminology that will facilitate the international and transdisciplinary development of the field. It is important to actively educate individuals on the life care planning team concerning specific terminology that defines and describes areas of assessment and treatment within the field of communication sciences and disorders.

The SLP must perform his own case intake, consisting of talking with the referral source, determin­ing the time frames needed to complete testing, arranging the financial and billing agreements, and arranging for a release of all pertinent information. Additional testing needed may be identified at this time or during the initial interview arrangements.

The SLP will then review a copy of the medical records to include:

¦    Nursing notes

¦     Doctor’s orders

¦     Other services’ reports

¦     Educational information

¦    Vocational information

¦     Day-in-the-life videos

¦     Other relevant documentation, depending on the etiology and diagnosis

A thorough assessment battery is then administered, gathering information from the spouse, family, or other relatives, including the clients themselves. This step may also include the oppor­tunity for the SLP to consult and interview other team members whose information may have a bearing on final recommendations of the SLP. At this time, if additional medical, clinical,
vocational, or educational information or evaluations are needed, requests for these additional information-gathering steps should be submitted to the referral source. A letter may be composed outlining the correct questions with supporting data to ensure that the SLP has the opportunity to solicit the needed information.

At the completion of the assessment, the SLP must be able to provide a written report, documenting the test results, observations, and conclusions with clear recommendations. These recommendations must be detailed to include a projection of future care costs, frequency of service or treatment, duration, base cost, source of information, and recognized vendors or manufacturers, current prices, collaborative sources, and categories of information. It is recommended that the consulting SLP be knowledgeable about the local sources and costs of these recommendations, either through direct contact with suppliers or through catalog and desktop/ computerized research. Recommendations from the SLP should be discussed with the client and family, treatment team members, and other life care team members if they directly impact the final recommendations and the cost analysis of the plan by the economist. Any coordination and agreement needed between team members including the economist should occur at this time. A draft of the communication sciences and disorders assessment and recommendations report should be written and distributed to the life care planner for review relative of the accuracy and completeness of the information. The SLP must be able to explain, from a life care planning perspective, the reasons and rationales that are relative to their recommendations. These must be lifelong recommendations and objectives, developed in an integrated format. Once the document is correct and complete, a final draft should be compiled and distributed to the life care planner and the referral source. It should be determined, by these two parties, whether the written documentation should be sent to other internal life care planning team members, including the family and client, and to external individuals.

There are four methods of gathering and interpreting quantitative and qualitative information about the client that should be used in the communication sciences and disorders assessment pro­cess by the SLP. These four measures are a collection of the initial database, interview procedures, clinical assessment, and formal assessment procedures (Dunn & Dunn, 1991). Often more than one method is used to gather information about the same aspect of a client’s skills and abilities, the context, the activity, or the use of technology or equipment. Information collected should include the reason and need for referral, medical diagnosis, and educational and vocational background information. This information is collected during the referral and intake phase, and its purpose is to provide preliminary data for planning the assessment. The interview takes place during the identification phase as a means of gathering information regarding the consumer and her needs. It is important that the consumer, family members, rehabilitation or education professionals, and other care providers be interviewed.

Formal assessment procedures are administered in a prescribed way and have set methods of scoring and interpretation. Therefore, they can be duplicated and analyzed. They may or may not be standardized. Clinical assessment techniques involve skilled observation of the consumer and are used throughout the assessment process. These techniques may be structured so that a series of steps is followed to determine specific skills, or they may be intentionally left unstructured to see what takes place. Observation can be done during a simulated task in a clinic setting or in a context familiar to the consumer such as a classroom or workplace. Differential diagnosis is an
ongoing and essential component of the assessment process and one that requires an advanced level of understanding and perspective about the trauma or injury.

Evaluating children (pediatric and adolescent) presents complex and challenging issues, compli­cated by the catastrophic nature of the disease, disability, or trauma and frequently challenged by the almost insurmountable task of planning a child’s life. For these reasons, it is critical to make accurate and thorough projections and careful analysis of the disability, educate team members and caregivers about the pediatric disabilities, and develop a differential diagnostic therapeutic approach to service delivery to the child. The list of pediatric and adolescent considerations in the communication sciences and disorders assessment is lengthy, detailed, and can be complex. It is important to disclose that the list is not all-inclusive, because changes occur as research and science enhance the process.

There are areas that warrant consideration when performing a communication evaluation for a pediatric or adolescent individual that are not considered, or at least not in the same detail, when evaluating an adult. Chronological age and pretrauma development are used as the normal bench­marks against which to measure the disability issues. Routine medical needs must be addressed to the pediatric specialists who would provide the information that impacts a child’s communication development. These include pediatric physiatry, otolaryngology, pediatric neurology, developmen­tal medicine, audiology, dental/orthodontic, prosthodontist, and pediatric neuro-ophthalmology and ophthalmology. It should be noted here that there is a trend in the medical specialty fields to identify specialists who work solely with adolescents. Additional cognitive and educational infor­mation is gathered from the following sources:

¦     Educational consultants to private and public educational programs

¦     Personal caregivers and attendants

¦     Pediatric neuropsychological assessment

¦     Occupational and physical therapy

¦    Vision and hearing specialists

¦     Evaluators of driving

¦     Programs for the development of social and pragmatic skills

¦     Prevocational and vocational training programs

One area receiving an increased amount of attention at this time is autism. Autism (autistic disor­ders) is within the broader diagnostic category of autism spectrum disorder (ASD). Other diagnoses in the category include Asperger’s syndrome, pervasive developmental disorder (PDD) (sometimes referred to as PDD-NOS), and childhood disintegrative disorder. All of these disorders occur in males approximately four times more often than in females. In earlier years, autism affected 1 in 500 children; however, with the explosive increase in the United States (and apparently in other countries), whether because of better diagnoses or actual increases in cases, it is now estimated that

1   in 150 children ages 10 and younger are classified as having some form of ASD (Bishop, 1989; Gillberg, 1991; Tonge, 2002; Owens, 2004). SLPs are aggressively involved in treating children and adolescents with ASD.

The SLP, as an outcome of the assessment results, frequently provides AT or augmentative and alternative communication (AAC) recommendations. AT is defined as any technology used to enable individuals to perform tasks that are difficult or impossible due to disabilities (Lloyd et al., 1997). AAC itself is defined as the supplement or replacement of natural speech or writing using aided or unaided symbols, and the field is referred to as the clinical/educational practice to improve the communication skills of individuals with little or no functional speech (Lloyd et al., 1997). It is important to be knowledgeable about the laws and policies that support the use of AT or AAC. The list of federal mandates that relate to the use of AT, the development of AT services (evaluation and therapy), and the integration of AT devices and services into medicine, education, independent living, and vocational arenas is lengthy. The partial list of mandates as shown in Table 9.6 continues to change (and improve) and is not considered to be inclusive. It is included to give readers an idea of the growing list of political directives that acknowledge the consumer’s need for AT devices and services.

Industrial advancements and competition have driven the recent development of AT devices, but the development of services and service delivery in the United States has been influenced significantly by federal legislation. Over the last 40 years, the federal government has enacted a series of bills and initiatives requiring federal agencies, states, and private industry to support the employment of people with disabilities. Milestones over the 40 years include the following most recent legislation.

The Rehabilitation Act of 1973 mandates reasonable accommodation in federally funded employment and higher education for AT and services. This act has established several important principles upon which subsequent legislation has been based. These include reasonable accommodations in employment and in secondary education. The act mandates that employers and institutions of higher education receiving federal funds seek to accommodate the needs of employers

Federal Mandates

Section 504 of the Rehabilitation Act of 1973

Rehabilitation Act of 1973, reauthorization and amendments of 1993 and 1998 Individuals with Disabilities Education Act (IDEA), PL 101-476

Technology-Related Assistance for Individuals with Disabilities Act of 1988, PL 100-407

Technology-Related Assistance for Individuals with Disabilities Act Amendments, PL 103-218

Americans with Disabilities Act (ADA) of 1990, PL 101-336

Goals 2000: Educate America Act, PL 103-85

Improving America’s Schools Act, PL 103-382

Telecommunications Act of 1996, PL 104-104

Telecommunications for the Disabled Act of 1982

Telecommunications Accessibility Enhancement Act of 1988

Rehabilitation Act, Section 508

Decoder Circuitry Act
and students who have disabilities. It specifically prohibited discrimination in employment or admission to academic programs solely on the basis of a handicapping condition. Sections 503 (educational institutions) and 504 (employers receiving federal funds) of this act describe both reasonable accommodations and least restrictive environment (LRE), a term relating to the degree of modification in a job or academic program that is acceptable. Many of the efforts to achieve accommodations in the least restrictive environment involved the use of assistive technologies.

The Education for All Handicapped Children Act (EHA) of 1975 extends reasonable accom­modations for students from ages 5 to 21, providing a free, appropriate public education (FAPE). This act initiated procedures to ensure that each public school system identifies and provides all children with disabilities with an education. States were also mandated to establish procedures for enforcement. AT plays a more significant role in gaining access to educational programs. The act created the individual education plan (IEP) to be made for all students with disabilities. This act, also known as PL 94-142, established the right of all children to a free and appropriate education, regardless of handicapping condition. When PL 94-142 passed, children with disabilities who were not in school programs or those who were but who were not receiving services began individual education plans (IEPs) with measurable goals, AT, and services. Lack of local services or lack of funding was not a reason to deny services. The impact of this law has been far reaching. Devices ranging from sensory aids (visual and auditory) to augmentative communication devices to spe­cialized computers have been utilized to provide access to educational programs for children with disabilities. Several additional acts leading up to PL 94-142 gave the foundation for the passage of this act.

The passage of the Elementary and Secondary Education Act (PL 89-10) in 1965 to improve quality of education for individuals and the passage of Elementary and Secondary Education Amendments for Children with Handicaps (PL 89-313) established the foundation for future legislation dealing with children with handicaps. The zero reject principle is the principle developed out of EHA, stating that all children, regardless of the severity of their disability, have a right to special education services. These services are provided by the local education agency (LEA) in the LRE. The Handicapped Infants and Toddlers Act of 1986 extended the preceding act to children ages 5 and under, expanding emphasis on educationally related AT.

Assistive technology (AT) includes both devices and services. The Individuals with Disabilities Education Act (IDEA) (reauthorized in 2004) defines an AT device as any item, piece of equip­ment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities. Devices can replace a missing limb, help prevent the worsening of a condition, improve physical functioning, increase a person’s capacity to learn, or strengthen a physical or other weakness. AT services support people with disabilities or their caregivers to help them select, acquire, or use AT devices. Such services also include functional evaluations, training on or demonstration of devices, and purchasing or leasing devices. Specifically, AT services include the following:

¦    Evaluating the needs of an individual with a disability, including a functional evaluation of the individual in the individual’s customary environment

¦    Purchasing, leasing, or otherwise providing for the acquisition of AT devices by individuals with disabilities

¦    Selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing of AT services

¦    Coordinating and using other therapies, interventions, or services with AT devices, such as those associated with existing education and rehabilitation plans and programs

¦     Training or technical assistance for an individual with disabilities or family of an individual with disabilities

¦     Training or technical assistance for professionals (including individuals providing educa­tion and rehabilitation services), employers, or other individuals who provide services to, employ, or are otherwise substantially involved in the major life functions of individuals with disabilities

AT can help people learn, compete in the work environment, achieve independence, or improve quality of life. Although the use of AT is not an end in itself, it is part of an ongoing therapeutic process to improve functional capabilities.

Aids for Daily Living: Self-help aids for use in activities such as eating, bathing, cooking, dress­ing, toileting, home maintenance, and so on. Examples include modified eating utensils, adapted books, pencil holders, page turners, dressing aids, and adapted personal hygiene aids.

Aids for Hearing Impaired: Aids for specific populations including assistive listening devices (infrared, FM loop systems), hearing aids, TTYs, visual and tactile alerting systems, and so on.

Aids for Vision Impaired: Aids for specific populations including magnifiers, Braille or speech output devices, large-print screens, closed-circuit television for magnifying documents, and so on. Augmentative and Alternative Communication (AAC): Electronic and nonelectronic devices that help persons with speech and/or hearing disabilities communicate: communication boards, speech synthesizers, modified typewriters, head pointers, and text-to-voice software.

Computer Access Aids: Headsticks, light pointers, modified or alternate keyboards, switches acti­vated by pressure, sound or voice, touch screens, special software, and voice-to-text software that enable persons with disabilities to use a computer. This category includes speech recogni­tion software.

Environmental Controls: Electronic systems that help people control various appliances, switches for telephone, TV, or other appliances activated by pressure, eyebrows, or breath. Home/Workplace Modifications: Structural adaptations that remove or reduce physical barriers: ramps, lifts, bathroom changes, automatic door openers, and expanded doorways.

Mobility Aids: Devices that help people move within their environments: electric or manual wheelchairs, modifications of vehicles for travel, scooters, crutches, canes, and walkers.

Prosthetics and Orthotics: Replacement or augmentation of body parts with artificial limbs or other orthotic aids such as splints or braces. There are also prosthetics to assist with cognitive limitations or deficits, including audiotapes or pagers (that function as prompts or reminders).

Recreation: Devices to enable participation in sports, social, cultural events. Examples include audio description for movies, adaptive controls for video games, adaptive fishing rods, cuffs for grasping paddles or racquets, and seating systems for boats.

Seating and Positioning: Adapted seating, cushions, standing tables, positioning belts, braces, cushions and wedges to maintain posture, and devices that provide body support to help people perform a range of daily tasks.

Service Animals: The Americans with Disabilities Act defines a service animal as any guide dog (for visually impaired and blind individuals), signal dog (for hearing impaired or deaf individuals), or other animal individually trained to provide assistance to an individual with a disability.

Vehicle Modifications: Adaptive driving aids, hand controls, wheelchair and other lifts, modified vans, or other motor vehicles used for personal transportation.

The 1986 amendment to the Rehabilitation Act of 1973 required all states to include provision for AT services in the rehabilitation plans of the state vocational rehab agencies. Section 508 man­dates equal access to electronic office equipment for all federal employees. Technology-Related Assistance for Individuals with Disabilities Act (Tech Act) of 1988 mandates consumer-driven AT services and system changes in the states. This act created the development of the Tech Act programs throughout the country. The act was reauthorized in 1994. This legislation authorized funds for states to establish and implement a consumer-responsive, statewide program of technolo­gy-related assistance for individuals with disabilities, including identification of barriers to admin­istering this assistance.

The Americans with Disabilities Act (ADA) (PL 101-336) of 1990 (reauthorized in 2002) pro­hibits discrimination based on disability in employment, transportation, and telecommunications. The ADA furthers the goal of full participation of people with disabilities by giving civil rights protection to individuals with disabilities that are like those provided to individuals on the basis of race, sex, national origin, and religion. It guarantees equal opportunity for individuals with disabilities in employment, public accommodations, transportation, state and local government services, and telecommunications. President George H. W. Bush signed the ADA into law on July 26, 1990. Copies of the full Americans with Disabilities Act of 1990 may be obtained at no cost from the U.S. Subcommittee on Disability Policy, 113 Hart, Senate Office Building, Washington, DC 20510. The ADA Private Transportation hotline is (202) 224-6265.

The IDEA of 1991 (Public Law 105-17 and the reauthorization of PL 94-142), which became the Individuals with Disabilities Improvement Act (IDIA) of 2003, mandates that all local educational agencies provide AT devices and services to benefit students with disabilities. The IDEA mandate includes that local educational agencies be responsible for providing AT devices and services if these are required as part of the child’s educational or related services or as a supple­mentary aid or service. AT devices are identified in the IDEA as “any item, piece of equipment

Tech Act Priorities

To promote public awareness of AT at the national level

To provide training and education about AT on a national basis for stakeholders, including other national social service and business organizations, members of the insurance and health care industry, and public office holders/policy makers

To develop positions on a full range of national AT- and disability-related issues and to share these positions with other organizations or policy makers, as needed, to ensure that the views of the states and territories and their consumers with regard to AT service delivery are adequately represented

To provide a forum for exchanging information and promoting the system change accomplishments and activities of the Tech Act projects

To identify the need and opportunities for the development of nationally conducted activities to increase access to AT

To develop and promote a national agenda or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve the functional capabilities of children with disabilities” (Section 300.5). The IDIA was also aligned with the No Child Left Behind (NCLB) Act of 2001. Refer to www.asha .org for additional information on IDEA, IDIA, and NCLB.

The definition of an AT device, as provided in the IDEA, is very broad and gives IEP teams the flexibility that they need to make decisions about appropriate AT devices for individual students. AT includes a range of low and high technology, hardware and software, and technology solutions that are generally considered instructional technology tools if they have been identified as educationally necessary and documented in the student’s IEP. The need for AT is determined by the student’s IEP committee as educationally necessary. AT service is any service that directly assists a child with a disability in the selection, acquisition, and use of an AT device. The term includes (1) the evaluation of the needs of a child with a disability, including a functional evaluation of the child in the child’s customary environment; (2) purchasing, leasing, or otherwise providing for the acquisition of AT devices by children with disabilities; (3) selecting, designing, fitting, customiz­ing, adapting, applying, retaining, repairing, or replacing AT devices; (4) coordinating and using other therapies, interventions, or services with AT devices, such as those associated with existing education and rehabilitation plans and programs; (5) training and technical assistance for a child with a disability or, if appropriate, that child’s family; and (6) training or technical assistance for professionals (including individuals or rehabilitation services), employers, or other individuals who provide services to employ or are otherwise substantially involved in the major life functions of children with disabilities (Section 300.6). The rules and regulations for special education in each state may also address the provision of assistive devices and services in various sections of the state’s educational policy and regulations, including the definition of assistive devices, the definition of service, within what parts of the IEP AT may be included (related services, supplemental aids and services, etc.), whether AT is needed to provide the student a FAPE, whether an AT assessment is needed, if AT is needed for the student to participate in local or state testing, and whether the technology is needed in a nonschool setting.

The reauthorization of the Rehabilitation Act of 1973 (1992) (1997) mandates rehabilitation technology to be a primary benefit to be included in the rehabilitation plan for the state rehabilitation agencies. The rehab plan was required to include how AT will be used in the rehabilitation process of each individual client. In 1992, Congress passed the reauthorization of the Rehabilitation Act of 1973. This legislation (PL 102-569 in 1992 and PL 105-17 in 1997) makes the rehabilitation act consistent with the principles of self-determination of the ADA, and it is more consumer responsive than the original version. Rehabilitation technology is defined in this law to include rehabilitation engineering and AT devices and services. Under this legislation each state must specify how AT devices and services or work site assessments are to be provided. The individualized written rehabilitation plan (IWRP, but now referred to as the Individual Work Plan, or IWP) must include the provisions of rehabilitation technology services to assist in the implementation of intermediate and long-term objectives, and rehabilitation technology is exempt from what are termed comparable benefits funding considerations. The latter concept means that vocational rehabilitation monies are considered to be the first source of funding for purchase of AT regardless of whether the individual has other funding sources. Also included within the mandate of this legislation was the continuation of rehabilitation engineering research centers, which focus on one or more core areas of research and development.

The Ticket to Work and Work Incentive Improvement Act of 1999 provides consumer choices for the provision of vocational rehabilitation and job training and other support services. The Ticket to Work and Work Incentive Improvement Act of 1999 has a number of incentives that can
be offered to benefit recipients to help them reintegrate into the workplace. Agencies that provide employment training and job placement to people with disabilities will receive a fixed portion of that person’s prospective Social Security case benefit when the individual goes back to work and in the first few years during the individual’s employment.

The New Freedom Initiative (February 2001) increases funding for research and development of AT resources nationwide. Although not legislation, this initiative also promotes full access to the community for people with disabilities through expanded transportation options, educational opportunities, and greater integration into the workforce.

SLPs (and audiologists) must address the unique privacy concerns, both ethical and regula­tory, that confront individuals who rely on AT and the SLPs and other practitioners who provide them with services (Blackstone et al., 2002). The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was created by Congress to provide guidelines for the protection of health care information and to establish standard formats for the electronic transmission of clinical data such as claims, referrals, explanation of benefits (EOB), remittance advices (RAs), and others. Although there are nine separate elements to the HIPAA legislation, the Department of Health and Human Services (DHHS) has thus far promulgated three in the form of final regulatory rules, the privacy rule and the transaction and code set rules, and the security of health care data as they are generated and stored by providers and others who have access to this protected information.

The privacy rule of HIPAA is intended as a federal floor to protect the privacy of individually identifiable health information contained in a patient’s medical record. The protected information includes a patient’s name, address, Social Security number, financial data, or any other identifying information in addition to the medical record itself. The rule creates substantial new compliance issues for covered entities, which include virtually all health care providers, health plans, health information clearinghouses, and those business associates who engage directly or through contractual arrangements with any of those. It also covers paper files containing this pro­tected information that is not yet in electronic form. In short, it covers all information, including both hard and soft files. The compliance date for the privacy rule was April 14, 2003. Substantial civil and criminal penalties, up to and including jail time, can be assessed for noncompliance.

The final HIPAA privacy rule covers all individually identifiable health care information in any form, electronic or nonelectronic, that is held or transmitted by a covered entity such as a health care provider, a third-party payer, or any of their business associates who come into contact with these data. Under HIPAA, there are legal penalties for covered entities that receive or use unauthorized information intentionally. SLPs, by transmitting personal health information (PHI) in electronic form, are regulated by HIPAA. The following points about HIPAA and AT should be followed to remain compliant.

SLPs should consider assistive devices that facilitate the security of PHI by providing essential design features, vocabulary, and training that emphasize the rights to privacy and informed con­sent of individuals who rely on assistive devices, strategies, and techniques. The SLP is responsible for making sure the PHI is not openly accessible. New devices offer both text and audio-data logging. These logs potentially put the user at risk if they are available to others. All AAC users should receive a copy of the provider’s Notice of Privacy Practices. The Notice of Privacy Practices explains how the provider will use the individual’s PHI and outlines the provider’s confidentiality program. SLPs should educate themselves on HIPAA regulations, should conduct a gap analysis of their practice policies and procedures, and should undertake a compliance implementation program. The privacy and safety of individuals using communication boards and AAC devices should be considered when including personal information (name, address, phone number, reli­gion, political affiliation, etc.). Remember that not all AT users understand the privacy issues, either. Eavesdropping, communication partners speaking loudly to interpret the message, and people reading what is on the screen are all potential violations of privacy. AT users need training to learn to protect their privacy and need help selecting vocabulary such as “Please do not read my display.” AT users also need training to coordinate their speech output to conform to public expectations of conversations, help to lower the volume of their device, password protection and encryption of the message buffer and data logging system in the AT device to protect the user’s content, and privacy/confidentiality training for their communication partners.