Sample AAC Report for ALS Client

Sample AAC Report for ALS Client
Here you will find a sample adult AAC evaluation report/funding request for a client with a diagnosis of Amyotrophic lateral sclerosis (ALS), for the purchase of the recommended voice output device. This report may provide assistance for your own report writing. However, it is strongly advised that you check the guide lines for funding with each insurance company you are submitting funding requests to. This report follows the suggested guidelines for Florida Medicaid funding as of Fall 2009. The device manufacturer’s funding department is the best resource for ensuring your report and funding packet will contain the most up to date requirements.

Speech Generating Device (SGD) funding requests must be submitted by a qualified speech-language pathologist and must be accompanied by a complete funding packet including but not limited to: a physician’s prescription for the SGD, copies of ALL the client’s insurance cards, a current list of medications, client information form, assignment of medical benefits form, client bill of rights, signed trial evaluation contract (if applicable), and statement of non-conflict of interest. All of these forms can be obtained through the funding department of the device manufacturer (check the manufacturer’s website). Funding packets must be submitted to the funding department of the device manufacturer.

Augmentative-Alternative Communication Assessment

Name: Silvia Senior
Address: XX Palomino Rd. Ft. Laduerdale, FL 33309
Telephone: XXX-XXX-XXXX
Medicare #: XXX-XX-XXXX-A
Insurance Name: Private Health Insurance
Policy #: XXX-XX-XXXX
Medical Diagnosis: ALS
Code: 335.21
Primary Physician:
Dr. Guy Happy
Speech-Language Pathologist:
Nicole Lilienthal, M.S., CCC-SLP

I. Current Communication Impairment:
Mrs. Senior is a female with severe dysarthria due to Amyotrophic Lateral Sclerosis (ALS). The intelligibility of Mrs. Senior’s speech was judged to be severely limited. Intelligibility was rated at 50% or lower, dependent upon the listener’s familiarity. Currently, Mrs. Senior’s speech is characteristic of Stage 5 ALS, is not intelligible, and must be supplemented with a Speech Generating Device (SGD) to be reliably understood by care givers. Speech intelligibility will continue to deteriorate. This patient will require the use of a SGD throughout the course of this disease.

II. Daily Communication Needs:
Mrs. Senior’s communication needs include: communicating to participate in family decision-making, communicating to participate in family leisure activities, communicating with extended family by telephone, attending and participating in support groups, participating in social outings within the community, reporting medical status and complaints, asking questions of medical providers, responding to medical provider's questions, discussing choices for end of life care, communicating with medical providers by phone.

Mrs. Senior currently communicates through a combination of natural speech and writing. She and her husband report that often listeners do not want to take the time to read her messages and she feels her needs are not being met within the community. Using a SGD will increase her speed of communicating by allowing her to store pre-made messages that she needs to say frequently. A SGD would also enable her to speak with health care professional and family members over the telephone independently. Mrs. Senior’s natural speech is less than 50% intelligible to unfamiliar listeners and thus is not a reliable method of communicating.

III. Augmentative Communication Trials:
Mrs. Senior was shown four different SGDs including: the LightWRITER, LanguageMaster, CrestSpeaker and the Link. She was unable to use the CrestSpeaker because she had difficulty selecting keys on the flat surface membrane keyboard. Mrs. Senior requires a light weight, highly portable device she can carry in a bag because she uses a walker to help her ambulate. The Link was considered not appropriate because it is less portable (larger and heavier) than the LightWRITER and LangaugeMaster. Speed of communication is an important factor in determining which device is appropriate for Mrs. Senior. The LanguageMaster was significantly slower. Due to the smaller key board, she had to type with two fingers rather than using all fingers to type. The LightWRITER, will enable her to generate messages significantly faster because she has good fine motor and typing skills. The LightWRITER also has the ability to print out her messages in the event she is communicating with someone who has difficulty understanding the synthesized voice due to a hearing impairment. Mrs. Senior and her primary communication partner, her husband, considered the voice quality of the LightWRITER to be clearer than the LanguageMaster. The LightWRITER also comes with a female synthesized voice where as the LanguageMaster does not. This was an important feature for Mrs. Senior and her husband.

IV. Cognitive and Physical Abilities to use the Device:
Physical Status: Mrs. Senior currently ambulates using a walker. She has good fine motor skills and is able to use direct selection. While Mrs. Senior is able to type using all fingers on a key board, she expressed difficulty in using a flat surface membrane key board due to the increased pressure that is required to activate the keys.

Language and Cognition: Language and cognitive skills were informally assessed and appear to be within normal limits. Mrs. Senior appears to have no cognitive or language difficulties in accessing any of the devices shown to her.

V. Rational for Device Selection:
Mrs. Senior requires a Speech Generating Device with the following features: word prediction, stored messages, easily activated keyboard (less pressure required to activate), full to medium size key board (accessed with two hands), telephone access, printed messages, high quality female synthesized voice, light weight and highly portable to meet her functional communication goals.

VI. Intervention Schedule:
An initial one hour individual session will be needed to train the client and her husband on the features of the device and how to trouble shoot problems that may arise. This session will also be used to give the client an opportunity to practice pre-programming messages that maybe useful at home and when interacting with her physician. Three additional follow-up sessions for 30 minutes each will be required to monitor the client’s progress in achieving her communication goals.

VII. Functional Communication Goals:

Immediate Goals: To be achieved following one, one hour training on the features of the device.

Mrs. Senior will independently communicate physical needs and emotional status to her husband on a daily basis, as needed.

Mrs. Senior will describe her physical symptoms and ask any questions when interacting with her physician and other health care professionals as needed.

Short Term Goals: To be achieved following two, 30 minute sessions.

1. Mrs. Senior will engage in social communication exchanges with immediate family and close friend at home.

2. Mrs. Senior will engage in social communication exchanges with family and friends in a variety of community settings.

Long Term Goal: To be achieved following one, 30 minute session.

1. Mrs. Senior will be able to ask questions and provide responses in community-based transactions, such as purchasing food in the food store or ordering a meal in a restaurant.

VIII. Recommended Device:
The Litewriter was determined to be the most appropriate device for Mrs. Senior because it will enable her to generate messages significantly faster than writing due to the word prediction and stored messages features. The LightWRITER also has the ability to print out her messages in the event that she is communicating with someone who has difficulty understanding the synthesized voice due to a hearing impairment. This device will enable her to communicate independently to health care providers, family and friends over the telephone. The LightWRITER is light weight and highly portable. Mrs. Senior will be able to carry the device in a bag while she ambulates using her walker. The quality of the synthesized voice of the LightWRITER is better than that of the LanguageMaster. It also comes with a female synthesized voice where as the LanguageMaster does not.

Purchase Information - The LightWRITER is manufactured by Toby Churchhill Ltd.
Toby Churchill House
Norman Way Industrial Estate
Cambridge CB24 5QE
United Kingdom
Tel: +44 (0)1954 281210
Fax: +44 (0)1954 281224

(Present in chart format the SKU #, Item Description, Cost per unit and Total Cost)

Mrs. Senior’s ability to achieve her functional communication goals requires the acquisition and use of the LightWRITER. This SGD represents the clinically most appropriate device for Mrs. Silvia Senior.

This report was forwarded to the treating physician (Dr. Guy Happy, 10 S. University Drive, Davie, FL 33314, 954-XXX-XXXX on 09/01/2003 so that he can write a prescription for the recommended SGD.

If you have any questions or concerns about this report, please contact Nicole Lilienthal for clarification or more information at 954-XXX-XXXX.

Nicole Lilienthal,MS,CCC SLP
Speech-Language Pathologist
Augmentative/Alternative Communication Specialist

Primary Care Physician's Signature

Statement of Non-Conflict of Interest

I hereby certify that I, Nicole Lilienthal, am a speech-language pathologist that adheres to all the standards of the American Speech-Language-Hearing Association and all other associations that support the field of Augmentative and Alternative Communication. I have a private practice in the state of Florida and work as a speech-language pathologist. As part of my ethical standards of practice, I hereby certify that all recommendations in this report were made for the best interest of Mrs. Silvia Senior. I have no financial interest nor receive any monetary compensation from any manufacturer for the sale of the recommended AAC technology. My only professional interest is in the communication success of Mrs. Silvia Senior.

Nicole Lilienthal, MS, CCC-SLP
Speech-Language Pathologist
Augmentative/Alternative Communication Specialist

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