AAC in Times of Change

Lisa M. Bruening, MS, CCC-SLPThe ALS Association

Northern Ohio Chapterlisa@alsaohio.org

en.wikipedia.org/wiki/augmentaive_and_alternative-communication

To move forward….…………Perhaps we need to look back…

1950’s

1960’s

en.wikipedia.com/wiki/aumentative_and_alternative_communication#mediaview/file:patient_operated_selector_mechanism

patient-operated selector mechanism (POSM or POSSUM)

praacticalaac.org Avoiding Insanity AAc & the Pace of Change, Carole Zangari

1970’s 1973: Rehabilitation Act 1975: P.L. 94-142 Knowledge Expansion

Bates and Dore Function over Form

Technology Expansion Microprocessor and switch technology

asha.org/public/speech/disorders/AACthreedecades

1980’s to 2000’s AAC: More Than Three Decades of Growth

and Development by Rose A. Sevcik and MaryAnn Romski “From laptop computers that talk as well as

perform a wide range of other operations (e.g., word processing, World Wide Web access) to computer linked devices dedicated to communication, technological advances during the 1980s and 1990s have produced numerous vehicles for communication.”

Medicare SGD NCD 2001

cue the angel chorus

Medicare SGD NCD 2001 Benefit Category 

Durable Medical Equipment

Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=274&ncdver=1&NCAId=8&ver=7&NcaName=Augmentative+and+Alternative+Communication+(AAC)+Devices+for+Speech+Impairment&bc=ACAAAAAAIAAA&

Indications and Limitations of Coverage 

Effective January 1, 2001, augmentative and alternative communication devices or communicators which are hereafter referred to as “speech generating devices” are now considered to fall within the durable medical equipment (DME) benefit category established by §1861(n) of the Social Security Act (the Act). 

They may be covered if the Medicare Administrative Contractor medical staff determines that the patient suffers from a severe speech impairment and that the medical condition warrants the use of a device based on the following definitions.

MAY BE covered if… Being a dedicated speech device,

used solely by the individual who has a severe speech impairment;

MAY BE covered if… May have digitized speech output,

using prerecorded messages, less than or equal to 8 minutes recording time;

MAY BE covered if… May have digitized speech output,

using prerecorded messages, greater than 8 minutes recording time;

MAY BE covered if… May have synthesized speech output

which requires message formulation by spelling and device access by physical contact with the device-direct selection techniques;

MAY BE covered if… May have synthesized speech output

which permits multiple methods of message formulation and multiple methods of device access; or

MAY BE covered if…software that allows a laptop

computer, desktop computer or personal digital assistant (PDA) to function as a speech generating device.

Devices that DO NOT meet definition Devices that are not dedicated

speech devices, but are devices that are capable of running software for purposes other than for speech generation, e.g., devices that can also run a word processing package, an accounting program, or perform other than non-medical function.

Devices that DO NOT meet definition Laptop computers, desktop computers, or

PDA’s which may be programmed to perform the same function as a speech generating device, are noncovered since they are not primarily medical in nature and do not meet the definition of DME. For this reason, they cannot be considered speech-generating devices for Medicare coverage purposes.

Devices that DO NOT meet definition A device that is useful to someone

without severe speech impairment is not considered a speech-generating device for Medicare coverage purposes.

Why Review these definitions?

Effective April 1, 2014,

CMS Classified SGDs

as Capped Rental

So why are we still fighting for access?

Technology Is Empowering, But Only If You Can Afford It

People with Disabilities Are Being Denied Access by New Medicare Restrictions

By Steve GleasonFormer NFL standout and ALS patient and advocatewww.teamgleason.org

Advocacy

200 Members of Congress

Sign Letter to CMS

Demanding Answers to

Questions about SGD

Funding

Keeping Issue in the Media

The Washington PostALS patients face loss of Medicare coverage for devices used to aid speechBy Shefali Luthra October 26, 2014

cue soundtrack: Guns n Roses, "Sweet Child of Mine"

Back to 1999

cue music: Prince "1999"

Feature MatchingFeature Matching is the systematic process by which a person’s strengths, abilities and needs are matched to available tools and strategies (Shane, H., & Costello, J. (1994) Augmentative communication assessment and the feature matching process. Mini-seminar presented at the annual convention of the American Speech-Language-Hearing Association, New Orleans, LA.& Costello, 1994).

Lois Jean Brady, SLP-CAS

www.proactivespeechtherapy.com loisjeanbrady@gmail.com

AAC Device Features Submitted by AAC TechConnect; Part of the ACES Module

Copyright 2011 AAC TechConnect, Inc

How to decide between Apps and Devices.Submitted by AAC TechConnect; Part of the ACES Module

Copyright 2011 AAC TechConnect

URL: http://guides.mclibrary.duke.edu/ebmtutorial

Balancing Act

Patient needs

Clinical Recommendations

costs

Bulbar onset

yassermetwally.files.wordpress.com

Speech Intelligibility Decreasing

May need to write a specific word to state the topic of conversation

May need to point to letters of words on a letter board

May need to write most of what they are saying with pen and paper, Boogie Board LCD Slate

May need to use texting for face to face and emailing instead of telephone

May begin to use consumer products to supplement or replace natural speech: iPhone, iPad, Android table, Blackberry

May consider AAC device (lightwriter, dynawrite, maestro, etc. for those with limited experience with technology)

May begin to use keyboard text entry via text to speech output on laptop (Read Please, E-triloquist, ect.)

May need to use TTY, speech to speech, or internet relay for telephone conversations

Review iPhone, iPads and Androids

Windows tablets

Pen and paper

White boards/Dry Erase

Boogie Boards- electronic LCD slate

Text-to-Speech Software (Windows)

CHIPSpeaking, FREE, www.chipspeaking.com E-triloquist, FREE, www.etriloquist.com Natural Reader, FREE,

www.naturalreaders.com/download.htm Read Please, FREE, www.readplease.com TextOutloud, $30, www.nextup.com CoolSpeech, $30, www.bytecool.com

There are many others….changing all the time

Limb Onset

ohemassmd.blogspot.com/2014/08/als-amyotrophic-lateral-sclerosis.html

Early Stage Voice Banking: recording messages in

their own voice through the sound recorder on a computer

Begin to develop their own “voice synthesizer” through software such as ModelTalker (http://www.modeltalker.com/)

The system uses representative segments of recorded speech (either from an individual who is losing the ability to speak or from a person chosen by someone who can no longer speak) to create a unique synthetic voice. This synthetic voice is virtually unlimited, meaning it can be used to express almost anything, including words and phrases not previously recorded.

Rate Enhancement Strategies

Different types of keyboards: size, shape, split

Ease of Access: onscreen keyboard, dwell/hover settings

Mouse Hardware settings: changing speeds, button locations

Alternative mouse devices Trackpads, trackballs, foot mouse,

joysticks, switches Camera mouse: tracks body

movement Head mouse devices

Ablenet Tracker Pro Origin Headmosue Extreme Smart Nav

Eye gaze device should be considered last*

* IMHO

Virtual Keyboard, Virtual Mouse Programs and other Input Software

vir·tu·alˈvərCH(əw)əl/adjective

synonyms: simulated, artificial, imitation, make-believe;

COMPUTINGnot physically existing as such but made by software to appear to do so."a virtual computer"

Better Living Through Technology. www.bltt.org/physical/index.htm

Onscreen keyboard Searchhttp://www.bltt.org/software/osk.htm

Charlie Danger: Occupational Therapist, site authorBetter Living Through

Technology

Windows On-screen Keyboard

Allows person to bypass the computer keyboard. Windows Accessibility Features allows a window with a keyboard display to be active on the screen. Text may be selected via mouse or mouse alternative and then placed into the active window or text box of the intended program.

Virtual Mouse Programs Dwell Clicker  FREE Point-N-Click  FREE The Grid Tobii Communicator EZ Keys

Onscreen Mouse Software

Point-n-ClickVirtual Mouseby Politalwww.polital.com/pnc

But wait! That’s not all…

Eye Gaze Control EyeGaze Edge by LC Technologies

Medicare compliant version; also available in tablet and desktop versions

Tobii Eye Tracking via PCEye Mobile and PCEyeGo (available as an add-on)

EyeTech Digital TM4/Mini, TM5/Mini (available as an add-on)

Eyepro GS (avaialble as an add-on) WordsPlus

EyeTribe- (available as an add-on)

The System Requirements (Tobii)Most add-on eye tracking work best on

Dell Latitude 10 Microsoft Surface Pro Lenovo ThinkPad Tablet 2 Samsung ATIV Smart PC 500T

Require full Windows Operating Systems

System Requirements (EyeTech) Microsoft Windows XP, 7, or 8 OS, 32-bit or

64-bit. USB Port Up to 20 in (50.8 cm) Monitor

Technical Specs (Tobii add-on) Generally, add-on eye tracking works best

if the following minimum specs are met:

CPU: 1GHz, 2 coresRAM: 2GBGPU: 60 MB video RAM, pixel shader version 2.0 or higher

Switch Scanning EZ Keys for Windows NeuroSwitch incoprates Assistiveware

(Mac and Windows) Settings on many other programs allow

switch scanning

Scanning Animation: Step 1

Scanning Animation: Step 2

But Wait! There’s more….

Communication Software for PC (www.oatsoft.com listing of open source AT software)

Tobii Communicator The Grid E-triloquist EZKeys

AAC Software Search http://www.pinterest.com/vsucsd/aac-software/

AAC Resources on the Webhttp://www.pinterest.com/amyandpals/

Case Studies How can we meet communication needs

with consumer products?

Stephen Hawking

The System Lenovo ThinkPad X220 Tablet (2 copies)

Intel® Core™ i7-2620M CPU @ 2.7GHz Intel® 150Gb Solid-State Drive 520 SeriesWindows 7

Speech Synthesizers (3 copies):Manufacturer - Speech Plus (Incorporated 1988, Mountain View, CA)Model - CallText 5010

EZ Keys, written by Words Plus Inc A cursor automatically scans across this

keyboard by row or by column. I can select a character by moving my cheek to stop the cursor. My cheek movement is detected by an infrared switch that is mounted on my spectacles.

This switch is my only interface with the computer. EZ Keys includes a word prediction algorithm, so I usually only have to type the first couple of characters before I can select the whole word.

When I have built up a sentence, I can send it to my speech synthesizer. I use a separate hardware synthesizer, made by Speech+.

Through EZ Keys I can also control the mouse in Windows. This allows me to operate my whole computer. I can check my email using the Eudora email client, surf the internet using Firefox, or write lectures using Notepad.

Steve Gleason

Most pALS must choose btwn:a) silenceb) archaic communication. IE. blinkingc) paying $20k for a system weaker than ur 1980s computer-SG#detAiLS

Online communication via text, voice, video, and social media is a daily requirement. In order to stay engaged in life and be productive, PALS often require all of these communication methods simultaneously. To have hardware up to this task is a necessity and the current “brand name” offerings are severely deficient. Finally, these systems are incompatible with Apple/Mac products.

The current and future generations of pALS are “wired”. We create, edit, stream and share media from everywhere. We meet, communicate and collaborate with friends, family, colleagues, doctors and others online in real time from anywhere. We are productive and we want devices to facilitate our production.

I do not believe in complaining. I believe in doing. I do not believe in calling for change. I believe in making change. If I have my way, this change will happen. In making this change, we will also change the way the rest of the world communicates.

I do not believe in complaining.I believe in doing.I do not believe in calling for change.I believe in making change. If I have my way, this change will happen. In making this change, we will also change the way the rest of the world communicates.

References and ResourcesAAC: Where We’ve Been, Where We Are & Where We’re Headed Nationally David E. Yoder, Ph.D. CCC/SLP

Prof. Emeritus Speech & Hearing Science Director Emeritus/Senior Associate Center for Literacy & Disability Studies School

of Medicine, UNC-Chapel Hill

Learning Guides http://www.makoa.org/computers.htm#guide http://www.aactechconnect.com/ http://

www.assist-it.org.uk/assets/content/switch_access.htm