EXAMPLE 70 YEAR OLD WOMAN WITH PROFOUND DYSARTHRIA SECONDARY TO ALS

 

Facility Name

Department of Speech-Language Pathology

Facility Address and Phone Number

 

MEDICARE FUNDING REQUEST FOR SPEECH GENERATING DEVICE

 

1. Demographic Information

Patient’s Name:                                                       Social Security Name:

Date of Birth:                                                             Phone Numbers:

Address:

 

Patient’s Primary Contact Person:                   Relationship to Patient:

Address:                                                                      Phone Numbers:

 

Medical Diagnosis:

Date of Onset:                                                         

Date of Evaluation:                                                 Date of Request:

 

Physician:                                                                   Phone Number:

Speech Language Pathologist:                           Phone Number:

 

1. CURRENT COMMUNICATION IMPAIRMENT
   1. General Statement

Impairment Type & Severity (ICD-9) Diagnostic Code:        )

Secondary to ALS, Mrs. ____________ presents with a profound Sysarthia and is functionally nonspeaking.  Produces differentiated vowels with varying intonation.  Imitates monosyllabic words, with referent known with _______% intelligibility.

 

Oral motor control limited to gross movements only, and these movements are imprecise, reduced in range and executed slowly (e.g. open – close mouth, protrude tongue).  Patient receives nutrition through gastrostomy tube.  Spontaneous speech is limited to vocalizations.

 

Anticipated course of Impairment

Based on the Severe Dysarthria due to Amyotrophic Lateral Scierosis Staging Scale (a 5-point scale, with 1 being no detectable speech disorder and 5 being no useful speech), patient’s speech is characteristic of Stage 5 – No useful speech.  Given the patient’s current status and progressive nature of ALS, it is anticipated that Mrs. ________’s condition will deteriorate further.

 

1. Comprehensive Assessment

 

Hearing

No problems with hearing noted or reported.  Patient passes pure tone audiometric screening for octave frequencies at 25 dB from 500-4000 Hz.  Attends to and discriminates natural and synthetic speech at conversational loudness levels.  Husband may have slight hearing loss, although his hearing has yet to be formally assessed.  Husband successfully discriminated synthetic speech in SGD, at sentence levels, given occasional repetition (of spoken message) and reliance on visual display.  Patient and primary communication partner possess hearing abilities to effectively use SGG to communicate functionally.

 

Vision

Patient wears bifocal glasses at all times.  Show no problems with visual attention, scanning, tracking, or acuity with glasses on.  Discriminates ¼” test on display positioned at midline, at a distance of approximately 18” without difficulty.  Possesses visual abilities to effectively use SGD to communicate functionally.

 

Physical

The patient is wheelchair dependent.  Has an electric wheelchair (Jazzy 1100 with a right joystick controller).  Drives chair independently and safely,  Seating Tolerance approximates 2-3 hours.  Patient referred to physical therapist for recommendations to improve seating comfort and tolerance.  Patient spends several hours/day in a standard recliner chair.  Needs access to SGD from both wheelchair and recliner.

 

Patient reports weakness in both upper extremities.  Patient is right hand dominant.  Able to type on standard keyboard using middle right finger and left index finger.  Types quickly and with few errors.  No indication of fatigue or discomfort after typing several sentences.  Does not require keyguard at this point in time.  Accommodations may be required as ALS progresses (e.g. keyguard, scanning module/swith).  Patient possesses the physical abilities to effectively use a SGD with noted accessories to communicate functionally.

 

Language Skills

Informal assessment reveals oral and written language skills within functional limits.  Patient answers abstract yes/no questions with 100% accuracy and follows multistage directions with 100% accuracy.  Answers multiple choice questions about a paragraph read silently with 100% accuracy.  Patient types grammatically correct, syntactically complex sentences.  Patient formulates meaningful written paragraphs independently.

 

Cognitive Skills

Patient retains task instructions without difficulty.  Patient recalls 100% (5/5) of messages stored under abbreviations.  Patient identifies logical codes to abbreviate messages stored under abbreviations.  Patient identifies logical codes to abbreviate messages.  Patient spontaneously uses strategies to aid message production (e.g. abbreviates words).  Patient consistently gives partner feedback (using SGD and nonverbal cues) to indicate if message is accurately interpreted.  Patient corrects and clarifies message as appropriate.  Patient spontaneously and appropriately shifts between communication approaches to maximize communication efficiency.  Patient demonstrates ability to use word prompting and prediction.  Patient possesses cognitive/linguistic abilities to effectively use SGD to communicate and achieve functional goals.

 

1. DAILY COMMUNICATION NEEDS
   1. Specific Daily Communication Needs

Primary communication situations involve 1:1 and small group situations.  Primary environments are home and medical appointments.  Primary communication partners include husband, daughter, friends, paid caregivers, and medical staff.  Specific message needs include expressing needs, making requests, asking questions, offering information, and expressing feeling/opinions.  Patient expresses strong desire to maintain her role as a decision maker in the home, to socialize with friends and family, and to communicate directly with medical staff regarding her disease and treatment.

1. Patient has previously received speech maintenance therapy.  However, given the current severity of the patient’s speech impairment, coupled with the progressive nature of ALS, therapy to improve speech production is no longer indicated or appropriate.

 

The patient relies on yes/no responses, vocalizations, facial expressions, simple gestures (e.g. pointing to items in environment), alphabet board and desk top computers.  Unaided approaches are effective for calling attention and indicating very basic needs (e.g. pointing to a cup to request drink).

 

The alphabet board is used to generate novel messages during fact to face conversations with husband, daughter and a few close friends.  The board is adequate for basic needs that require a 2 or 3 word message; messages exceeding 2-3 words are difficult for partner to decode/retain.  The board also requires the partner to be standing beside the patient as she composes her message.  This can be tedious and time consuming for all partners and is not tolerated by medical personnel.  The board is ineffective in-group social situations, because not all partners can see the board and follow along as the patient spells.  The board is not effective with hired caregivers because they cannot read English.  The desktop computer is used to prepare messages in advance for either the husband or daughter.  The computer is not portable nor does it have voice output. 

 

The patient’s current communication approaches do not permit her to convey the type and complexity of information in the environments and with those partners with whom she interacts on a daily (i.e. husband, daughter, care givers) or intermittent basic (i.e. physicians, friends).

 

1. FUNCTIONAL COMMUNICATION GOALS

Upon receipt of SGD, therapy will target the following goals.  Ms. ___________(Patient) will:

• ·         Demonstrate ability to master basic maintenance and operations of SGD (on-off, adjusting menu features such as voice and display) with 100% accuracy (within 2 weeks)
• ·         Demonstrate ability to program stored messages independently with 100% accuracy (within 2 weeks)
• ·         Convey basic needs/make requests to caregivers, by spelling or retrieving pre-programmed message on SGD, independently and 100% accuracy (within 2 weeks)
• ·         Initiate social greetings, offer information, ask questions, express feelings and opinions through spelling and retrieving stored messages on SGD, during 1:1 and group situations with familiar and unfamiliar partners, independently and with 100% accuracy (within 3 weeks)
• ·         Use strategies on SGD to expedite message production when sharing information or asking question of medical personnel, independently and with 100% accuracy (within 3 weeks).

 

1.  Rationale for Device Selection
   1.  General Features of Recommended SGD and Accessories

Based on the above noted comprehensive assessment, daily communication needs, and functional communication goals, the patient requires SGD with the following features:

Input/Message Characteristic Features:

• ·         Direct selection with index and middle fingers of both hands/standard or mini keyboard (patient prefers QWERTY keyboard)
• ·         Flexibility to accommodate changes in physical access (i.e. alternative keyboard, scanning)
• ·         Accessible from multiple positions (i.e. wheelchair, Laxy Boy)
• ·         Alphabet based with access to stored messages (i.e. abbreviation expansion)
• ·         Access to word prompting or prediction to be used as a physical access declines.

Output:

• ·         Text-to-speech, speech synthesis (gives that patient has novel message needs and is relying on spelling as primary means to generate messages.
• ·         Two way visual display to aid husband (who has suspected hearing loss) to interpret message
• ·         Capability to facilitate communication at a distance

Other features:

• ·         Portable to accommodate conversational needs in various locations within home and at medical appointments
• ·         Long lasting battery to ensure device is operational in various locations and to minimize need to be close to electrical outlet

 

1. Recommended Medicare Device Category and Accessories Code

 

The individual’s ability to meet daily communication needs will benefit from acquisition and use of the SGD Category E2510 and equipment that enable device to be mounted from SGD accessory code (E2510)

 

1. Trials with SGDs

 

Patient participated in trials with 3 SGDs in Category E2510 that have the input and output features similar to those delineated above.  The SGDs included DynaMyte/DynaVox 3100, the Link, and the Allora.  Both current and future communication needs were considered as her physical condition is likely to deteriorate.

 

1. DynaMyte/DynaVox 3100.  Patient had difficulty with glare and motor access on the DynMyte and DynaVox.
2. Link.  After demonstration only used the Link to generate novel messages.  Used all function keys without difficulty.  Given the battery limitations, the inability to alter access methods. And the small visual display, the Link is not an optimal solution.
3. Allora.  The patient independently utilized the Allora to communicate her needs.  Spelled Lengthy, complex messages without difficulty.  Used function keys with 100% accuracy and recalled all messages stored under abbreviations.  The husband successfully interpreted all the patient’s messages relying on speech output and the visual display.  Any trial re:  future features.  I think we should include something that relates to scanning, e.g., patient was shown scanning features and was able to select messages using linear scanning.
4. Recommended SGD and Accessories

 

Based on comprehensive assessment and SGD trials, it is recommended that the patient be fitted with the Allora and wheelchair mount to secure the device and allow independent access.  The recommended wheelchair mount is designed to accommodate the Allora and will enable her to use the device throughout most of the day.

 

Allora and accessories are available from:

 

ACCI

P. O. Box 731

600 Commerce Drive, Suite 604

Moon Township, PA  15108

 

1. Patient and Family Support of SGD

 

The patient and her husband demonstrate motivation to maintain SGD.  The patient understood the pros/cons of different devices and identified the Allora as the optimal device for her needs.

 

1.  Physician Involvement Statement

 

A copy of this report has been forwarded to the patients’ treating physician (Dr. __________

, UPIN# _______, on ________________ date for review and prescription.

 

1.  Treatment Plan

Upon receipt of SGD, it is recommended that the patient receive 45 minutes of individual therapy and one hour of group therapy weekly for 8 weeks (16 sessions).  These sessions will address goals listed in Section IV of this report.  An additional two hours of training are recommended to train caregivers to program the device.

 

1. Signatures/SLP Assurance of Financial Independence.

 

The Speech-Language Pathologist performing this evaluation is not an employee of and does not have a financial relationship with the supplier of the SGD.

 

                Typed Name, Ms. CCC-SLP

                Speech Language Pathologist

                ASHA#  _________________

                State Lics. _______________