I’d like to talk about how to do AAC evaluations in the home. I’m sure I’m not alone in noticing an increase in the number of patients who could benefit from some form of AAC. It can be overwhelming, though. Many of us probably didn’t get much (if any) training in graduate school.
AAC, which stands for augmentative and alternative communication, is a big field. But we’re fortunate to have a large number of resources available to help us. I’m in no way an expert, but I have a fair amount of experience, and I’m constantly learning. This post is directed towards SLPs working with adults.
Free DIRECT download: AAC evaluation (cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Outline:
- AAC: the good news is also the bad news.
- A careful AAC evaluation saves time and gives better outcomes.
- Who is a candidate for using AAC?
- Types of AAC.
- Access methods.
- SLP Patricia Ourand’s overview of the AAC evaluation.
- How I do AAC evaluations in the home.
- You don’t have to be an expert to be effective.
- Related Eat, Speak, & Think posts.
- Next step: Dive into AAC resources.
AAC: the good news is also the bad news
The good news is that we have many options to choose from in order to help our patients. This means that with a careful evaluation, we are more likely to find communication solutions that work.
The bad news is that we have many options to choose form, and the list of options is only getting longer. As with any other area of speech-language pathology, we have to be proactive about staying in touch with advances in the field. We can’t recommend a solution that we don’t know exists!
A careful AAC evaluation saves time and gives better outcomes
The goal of an AAC evaluation is to find an effective communication solution for our patient. There’s nothing worse than taking the time to put together some form of AAC only to find it sitting on a shelf gathering dust while our patient continues to struggle to communicate.
Just as we shouldn’t stick to a handful of AAC options we’re familiar with, we also can’t try a ton of different options with any single patient. No one has time for that!
But a careful evaluation of our patient’s abilities and needs can narrow down the list of possible candidate AAC strategies and devices to trial. And that means we’re more likely to find a good AAC solution.
Who is a candidate for using AAC?
The short answer is anyone who is having trouble communicating. We may consider AAC if our patient is experiencing:
- Auditory comprehension difficulty.
- Word-finding problems.
- Expressive language difficulty.
- Impaired speech production (dysarthria, ataxia, or apraxia of speech).
- Voice impairment.
Common conditions that often require some form of AAC include:
- Stroke or cardiovascular accident (CVA).
- Traumatic brain injury (TBI).
- Other acquired brain injury (ABI).
- Glossectomy or laryngectomy.
- Progressive neurological disorder such as dementia, ALS, PPA, or Parkinsons disease.
- Temporary inability to speak, such as intubation in critical care or post-seizure recovery.
Types of AAC
AAC includes a spectrum of options, running from no-tech strategies (for example, blinking for “yes” and no response for “no”) to high-tech devices.
Different sources group AAC in different ways, so I’m going with what makes sense to me: no-tech, low-tech, mid-tech, and high-tech. Regardless, AAC is either unaided or aided.
Unaided AAC = no-tech AAC
If your patient isn’t using an external tool to support communication, but they’re doing something a typical user isn’t doing, then they’re using unaided AAC. Unaided AAC is synonymous with no-tech AAC.
No-tech AAC examples
No-tech AAC involves using your own body to support communication. For example:
- Using pointing, gestures, or signs.
- Blinking eyes for “yes” versus no response for “no”.
- Vocalizations.
- Facial expressions.
- Body language.
Aided AAC = low, mid, or high-tech AAC
If your patient is using an external object to communicate, then they are using aided AAC. Aided AAC falls into three categories: low-tech, mid-tech, or high-tech. See ASHA’s site for a different organization of AAC in their excellent overview.
Low-tech AAC
Low-tech AAC involves using non-powered tools to support or replace spoken communication.
- Objects.
- Pictures or photographs.
- Writing.
- Drawing.
- Communication boards.
- Communication books.
- Speech valve.
Mid-tech AAC
Mid-tech AAC includes equipment that require a power source and may provide voice-output using synthetic voice or recorded natural speech. These devices have a static display, meaning that the display doesn’t change when a button is selected. Mid-tech AAC devices generally have a limited capacity for stored messages. I include augmentative supports here.
For example:
- Attainment GoTalk 20+
- Logan ProxTalker (YouTube video)
- QuickTalker 23.
- Electrolayrnx.
- Voice amplifier.
High-tech AAC
High-tech AAC involves the use of computers, such as smartphones, tablets, and laptops. The device may be used as a full computer, or it may be a dedicated speech-generating device (SGD) that can only be used for communication. The AAC software may come with the device, or it may be an app that can be added to any compatible computer.
High-tech AAC devices offer a wide range of features, which may include:
- Dynamic display (navigate through different screens).
- Synthesized and/or digitized natural voice.
- Ability to include the user’s own voice via message banking or voice banking.
- Flexible display: text, symbol, image, or photograph.
- High capacity for stored messages.
- Ability to create novel messages.
- Customizable display to compensate for vision or cognitive deficits.
- Auditory cues.
- Rate enhancing features such as word prediction and abbreviation expansion.
- A variety of access methods.
Some well-known SGD vendors include:
Voice output options
Synthesized voice
A voice-output device may use a synthetic voice or a digitized voice. A synthesized voice is completely artificial, meaning the computer strings together individual sounds to create whatever message you want. Synthesized voices sound at least somewhat mechanistic and don’t reflect emotion. A voice-output device would say “I love you” with the same intonation as “It’s raining.” Anyone can create a synthesized version of their voice via voice banking.
Digitized natural voice
A digitized voice is a human voice that has been rendered into a format that the computer recognizes, such as a .wav file. Anyone can create a digital copy of their voice, with all of its expressive power, via message banking. The benefit is that you can have the SGD produce any message you’ve recorded in your own voice, with all of the personality and emotion you captured in the original recording. However, at this point, technology doesn’t allow you to create new messages in your natural-sounding voice.
Access methods
People can access an AAC device in several ways:
- Direct touch.
- Stylus.
- Mouse.
- Joy-stick.
- Head-mounted stick (YouTube).
- Head-mounted laser pointer (YouTube).
- A wide variety of direct-touch switches.
- Proximity switches, such as LITTLE Candy Corn.
- EMG switches, such as Neuronode Trilogy.
- Brain-controlled interface, such as intendiX or Unicorn Speller.
- Partner-assisted scanning.
- Eye-gaze direct selection (YouTube).
This likely isn’t a comprehensive list! I’m still learning about access methods, and will share more in the future.
SLP Patricia Ourand’s overview of the AAC evaluation
ASHA’s Professional Development has made this video freely available on YouTube. Patricia Ourand is a past president of the U.S. Society for Augmentative & Alternative Communication.
She discusses the barriers often faced by SLPs in doing assessments for communication devices, how we can improve our evaluations, and presents case studies.
How I do AAC evaluations in the home
1: Get to know my patient
In order to select AAC strategies or devices to trial, we need to get to know our patient pretty well. This should include:
- Current communication abilities and unmet needs.
- Cognitive, sensory, and motor skills.
- Anticipated changes to abilities and needs over time.
- Attitude towards various forms of AAC.
- Support system.
Communication
The first thing I do when I meet a new client is to assess their current communication abilities, using standardized and/or non-standardized methods. Each patient is different, so I tailor my assessment approach to fit my patient’s situation.
Basically, my goal is to determine their current abilities, impairments, and unmet communication needs. I want to know how my patient is communicating with their typical partners, and what happens during a communication breakdown. And I also want to know what their challenges and goals for life participation are.
I may use any of our typical standardized assessment tools to assess speech, voice, oral receptive and expressive language, reading, writing by hand, typing, and and pragmatic skills.
There are also various assessment tools available for adult evaluations, such as the ones listed on Praactical AAC‘s site.
I also consider anticipated changes in communication skills. In some cases, a person may reasonably improve their skills. While in others, they may lose ability (such as in progressive neurological conditions or certain types of cancer).
If the condition is not progressive (like ALS), then I always trial traditional therapy methods. Even when my patient is expected to improve with traditional therapy alone, I know that AAC strategies and devices can enhance traditional therapy. Pairing AAC methods with traditional therapy can improve long-term outcomes while providing short-term benefits.
Cognitive skills
Assessing cognitive-communication skills during AAC evaluations is important. Since we’re asking our patient to use a new tool and/or new communication strategies, we need to have a good understanding of what our patient’s cognitive-communication skills are.
However, there are no pre-requisites for using AAC. I still trial strategies or devices even when I’m not able to assess cognitive-communication skills. Sometimes my patients surprise me with what they’re able to use functionally.
If any neurological assessment results are available, we should include the pertinent information in our report.
Sensory and motor skills
In order to select the right AAC solution, we have to make sure our patient can successfully interact with the device. We need to have a good understanding of their vision and hearing status. We also need to understand how well they can move their body and any limitations they may have.
Ideally, we’d have access to reports or recent test results describing their vision and hearing status. Our OT and PT colleagues are important team members and can provide their expertise for modifying the device for low vision, improving physical access, and positioning.
Patient attitudes and available support
It’s important that our patient likes the strategy or device well enough that they’ll use it in their daily life. And many AAC solutions require buy-in from the family as well.
I once made the mistake of going ahead with a Lingraphica trial for a patient whose wife told me she didn’t want to learn how to use it. I had thought that she would change her mind if it helped and she could see how easy it was. After a short discussion, she agreed to the trial. But my patient ended up needing support from his communication partner, and it was too much for her. It was a waste of time and not something I plan to repeat.
Now, I’m more careful to pay attention to any hesitation. I explain the process and describe the training we can do, as well as the ongoing support available from the vendor. The entire time we work together, I’m teaching my patient and their caregiver how to find solutions to any problems they may have.
My goal is to find AAC strategies and tools that my patient and their loved ones will be comfortable with by the time I discharge.
2: Try out several AAC tools
Once we have our patient profile, we can select the AAC tools we think would be a good fit. I generally trial at least three different levels of AAC with my patients. If I’m considering an SGD, I always do hands-on trials with at least three devices from three different companies (including my iPad).
Getting a device into the home to try
I’ve worked with five different vendors during my home health career, and it’s pretty easy to set up trials. I simply contact the company to make the request. We schedule a time when it’s convenient for everyone, and I meet them at my patient’s house. The vendor rep is in charge of setting up the device and teaching the features, while I’m in charge of assessing my patient’s capabilities.
Some companies may ship the device and have the rep assist remotely. And all the companies offer remote tech support.
Every company I’ve worked with will allow us to loan a device for a few weeks in order to do a longer trial. We used to have to write a report to request a trial, but that’s no longer the case.
Your state AT program or other area organizations may have a lending library. Ablenet has a 2-week product loan program, available to all SLPs. If you know of other sources of devices to try, please comment below!
What to look for during trials with a device
During the trial itself, I assess my patient’s ability to:
- Select every cell in the grid on each page type.
- Type out novel messages on a keyboard (using any access method).
- Construct messages using pre-programmed words and phrases.
- Select pre-programmed sentences.
- Use the device for functional communication, for instance to make requests or answer questions.
Based on my patient’s language, cognitive, sensory, and motor abilities, I make changes to symbol type, font size, color contrast, number of messages displayed at a time, and so on.
I also try different access methods: direct touch, stylus, switch, and eyegaze. I just learned how much I didn’t know about access methods when I went to the ATIA 2019 conference, so I’m looking forward to getting hands-on practice.
AAC evaluations are a team effort
When there are any issues with positioning, range of motion, physical access, or low vision, I reach out to my OT and PT colleagues. Sometimes they come and directly work with the patient, and other times they make suggestions for me to try.
I’ve found that the vendor’s representative is often a great resource as well.
Use the evaluation process as time to educate and train your patient and family
Throughout the entire assessment process, I’m also making observations to determine what level of training and support my patient and their family will need following acquisition of the device. I offer some education and training at each visit, because it’s a lot for anyone to learn!
3: Final selection and the AAC evaluation report
Once we try out a few devices, we jointly decide with our patient and/or family which one we’ll recommend. I know funding can be a big issue, and you can find lots of information at AAC Funding Help.
Medicare, Medicaid, and private insurance require a comprehensive report from an SLP to support the purchase of a communication device. It’s beyond the scope of this article to discuss the report format, but you can find several examples and templates online such as these from PRC/Saltillo and ASHA. AACFundingHelp.com has a free AAC Report Coachwhich will help you write your report in Microsoft Word.
4: Training the use of AAC is extremely important
It’s critical that we provide sufficient training with the AAC strategies and devices we recommend. We should ensure that our patients are using the AAC tools in their everyday life. It’s also important that they know how to find help if and when any problems arise.
If our patient is using the AAC tools to effectively participate in their daily life, then the time we all invested was a success!
You don’t have to be an expert to be effective
As SLPs, we solve communication problems. The less we know about AAC, the harder it is to help our patients. The more we know, the easier it is to achieve better outcomes for our patients. I’m finding that every new thing I learn makes it that much easier to help the next patient.
As with any area in speech pathology, there are always professionals who know more than we do. We shouldn’t feel that we have to know it all in order to help the person in front of us. We’re not alone in this; there are many resources available to us.
Related Eat, Speak, & Think posts
- Free-low-tech AAC for adults.
- An easy guide to STS telephone relay.
- Voice banking tutorial: Acapela and ModelTalker.
- Easy voice banking with The Voice Keeper.
- Message banking tutorial.
- Top 10 AT and AAC research sources.
- ALS guide for SLPs.
Next step: Dive into AAC resources
In my next post, I’ll go deeply into the various resources available to help us: research, conferences, webinars, CEUs, blogs, newsletters, podcasts, equipment loans, training, and connecting with experts and other professionals.
What’s your favorite AAC resource? Please leave a comment below
Free DIRECT download: AAC evaluation (cheat sheet). (Email subscribers get free access to all the resources in the Free Subscription Library.)
Featured photo by Jonathan Velasquez on Unsplash.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
Hi,
Great information! I have a question about how much time and cost from start to finish would you say it takes to complete an evaluation up to the submission point? I know it varies but a ballpark would be helpful. I complete medical evals for my users who are starting their 19th year (I have them until 21) so when the district collector comes they still have their voice when they leave. I have done this at no cost for a few years but now feel compensation is fair.
Any help would be appreciated!
Hi, what an interesting question. I’m afraid I don’t have a good answer, as my services are covered by my salary. You may try contacting private practice SLPs who may charge for AAC evaluations separately from their other services.