Assistive technology (AT) devices allow people with disabilities to participate in activities of daily living. The AT evaluation team should determine goals and suggest appropriate AT devices and services to promote the use of AT by patients and their caregivers. Clinical assessments and physician responsibilities are summarized in this chapter.
Defining Assistive Technology (eSlide 19.1)
The term assistive technology describes tools used to enable people with disabilities to walk, eat, see, and otherwise conduct and participate in activities of daily living. Public law defines AT as “any item, piece of equipment or product system whether acquired commercially off the shelf, modified, or customized that is used to increase or improve functional capabilities of individuals with disabilities.” This definition also includes a second component, defining AT services as “any service that directly assists an individual with a disability in the selection, acquisition, or use, of an assistive technology device.”
Overview of Assistive Technology Devices (eSlides 19.2 and 19.3)
AT devices are designed to facilitate functional abilities and to meet the needs of humans. Considering one’s own interaction with technology gives insight into issues involved in the concept of the human-technology interface (HTI). Interaction commonly occurs through dials, switches, keyboards, handlebars, joysticks, or handgrips. Typical interfaces for direct selection, such as a computer keyboard or television remote control, are used by individuals with abilities to accurately choose an intended item because all possible options are presented at once and will be directly selected by individuals. Scanning switches that come in many styles (e.g., tongue touch, sipping and puffing, eye blink), the eye gaze switch, and the head mouse are examples of indirect selection methods used by severely disabled individuals to interact with their environment. HTI is also applicable for completing the feedback loop from devices back to the user. Good assessment skills and a focus on patients and their goals and needs are essential for HTI success and preventing abandonment of AT devices.
Assistive Technology for Communication Disorders (eSlides 19.4 and 19.5)
AT devices that meet the needs of people with many types of speech and language impairments are commonly called augmentative and alternative communication (AAC) devices. The use of AAC devices should be encouraged along with all other available communication modalities, such as gestures, vocalizations, sign language, and eye gaze. Nonelectronic AAC systems can be created with digital photographs, pictures from books or catalogs, or a marker to draw letters, words, phrases, or pictures. Digital voice output devices allow recording and storing of simple phrases in the memory of the device. When the user wants to speak, he or she simply presses a button and the device speaks the prerecorded message. However, these devices are not appropriate for individuals who need or want to communicate complex thoughts or feelings.
Synthesized speech is created by the software that uses rules of phonics and pronunciation to translate alphanumeric text into spoken output through the speech synthesizer hardware. Because numerous AAC applications (apps) are currently available, the use of touchscreen tablets, such as the iPad, has become highly popular and mainstream. Advantages of these systems are that they allow users to speak on any topic and use any word they wish. Among the latest developments for people who are completely locked-in are speech-generating devices that can be activated by a simple eye blink or by visually gazing on the desired area of the screen. The speech enhancer processes speech sounds for people with dysarthria, enabling improved speech recognition by others. The user wears a headset with a microphone attached to a portable device, and after processing, the clarified voice is projected via speakers.
Assistive Technology for Mobility Impairments (eSlides 19.6 and 19.7)
Motor impairments greatly affect the ability of individuals to interact with their environment. Early intervention and supportive caregivers and family members who are available to create modifications and incorporate AT devices into activities of daily living can help people compensate for impaired motor skills. Individuals can fully participate in life because many tasks can be accomplished through computers. Computers can perform education-related and work-related tasks and can monitor and control an unlimited array of devices and appliances at home, work, and school. Many AT devices have been developed to help individuals with upper body mobility impairment in using computers. Alternative computer keyboards come in many shapes, sizes, and layouts; onscreen keyboards are visible on the computer monitor. Voice recognition (VR) software has become essential for computer access for many individuals with motor impairment. AT solutions can include crutches, a rolling walker, a powered scooter, or a manual or powered wheelchair for individuals with lower body mobility impairments. Simple environmental modifications or adaptations can be indispensable facilitators for these individuals and might be all that is needed to increase participation.
Assistive Technology for Ergonomics and Prevention of Secondary Injuries (eSlides 19.8 and 19.9)
A rapidly growing area of concern for AT practitioners is the development of repetitive strain injuries (RSIs). Over the past few years, an entire industry of AT has been developed to deal with repetitive motion disorders. Electronic aids to daily living (EADL) provide alternative control of electrical devices within the environment and increase independence in activities of daily living. This technology is also referred to as environmental control units (ECUs). EADLs can be controlled directly by pressing a button with a finger or pointer or by voice command or controlled indirectly by scanning and switch activation. EADLs are primarily used at the home but can also be used at work or school.
Assistive Technology for Hearing Impairments (eSlide 19.10)
Hearing impairment and deafness affect the feedback loop in the human–environment interaction. AT devices, such as hearing aids and FM (frequency modulation) or radio wave systems, can be used to facilitate both auditory input and speech output. Other types of AT devices provide a visual representation, such as flashing lights of the auditory signal. Cochlear implants are inserted surgically with an electrode array placed within or around the cochlear structure when the hearing system is impaired at the level of the middle ear or cochlea. This system requires a battery pack worn on the body or behind the ear. It also requires an experienced audiologist to teach the individual to use acoustic cues produced by the cochlear implant as a substitute for natural hearing. Another recent adaptation for people with significant hearing impairments is computer-assisted real-time translation. This AT solution involves a specially trained typist or stenographer who records what is being spoken on a computer. The text is then projected onto a display, resulting in close to “real-time” translation. For individuals who wear hearing aids, the environmental adaptations frequently support individuals who are deaf or hard of hearing. Lip movements and gestures can also be helpful.
Assistive Technology for Visual Impairments (eSlide 19.11)
The term visual impairment technically encompasses all types of permanent vision loss or low vision. AT solutions conventionally involve the use of simple handheld magnifiers, large-print reading materials, or mobility devices (e.g., a white cane) for safe and efficient travel. High-contrast tapes or markers can also be used to indicate hazards in the environments. Braille text is still the first choice of many individuals for reading. Computers fitted with a speech synthesizer and specialized software allow navigation of the desktop, operating system, applications, documents, and the entire Internet. Any digital text can be heard aloud by the individual using this software. For individuals with some visual ability, screen magnification software enables the user to choose the amount (2–20 times) and type of magnification preferred for optimal computer access. Many magnification applications combine enlargement with speech synthesis or text-to-speech. People with visual impairment usually keep the setup of their home and work environments constant because this helps in locating items. To supplement these less technical aids, some individuals use electronic travel aids that have the capability of detecting obstacles missed by a cane. This technology uses ultrasound or information embedded in the environment, expressly for users who have limited vision.
Assistive Technology for Cognitive or Learning Disabilities (eSlides 19.12)
AT systems are being used to assist people with cognitive disabilities to learn new jobs/tasks and/or to prompt people through the various steps of a given task. Another system enables developers to use context-aware sensors in a multitude of environments and technologies to facilitate the safety, capacity, and well-being of people with cognitive disabilities using batteryless micropower sensors. There are a number of both low-technology and high-technology solutions available to assist literacy development, such as audiobooks or text-to-speech software that provides anticipation or multisensory feedback on the computer. VR can sometimes be helpful for people with learning disabilities. Some AT software systems provide auditory or visual prompts for individuals with cognitive disabilities. These system can be set up to prompt an individual through each step of a task.
Selecting Appropriate Assistive Technologies (eSlide 19.13)
Abandonment
Depending on the type of technology, nonuse or abandonment can be as low as 8% or as high as 75%. On an average, one-third of more optional ATs are abandoned, most within the first 3 months. To prevent abandonment, the AT team should include the individual with a disability and consider his or her opinions and preferences during the evaluation process.
Principles of Clinical Assessment
The goal of an AT evaluation is to determine whether AT devices and services have the potential to help an individual meet his or her activity or participation goals at home, school, work, or play. Other goals include (1) providing a safe and supportive environment, (2) identifying the need for AT services, (3) modifying or customizing ATs as needed, and (4) developing a potential list of recommended devices. Professionals from various disciplines should be chosen as members of the AT evaluation team based on the identified needs of an individual with the disability. It is not appropriate for an AT vendor to be called in to perform an AT evaluation, but the vendor can demonstrate its products and assist in setting up the equipment for evaluation when requested by the team. However, other team members, including the end user and his or her family, should perform the evaluation and make the final recommendations.
Phase 1 Assistive Technology Assessment
Phase 1 of the assessment process begins when a referral is received. Standard demographic and impairment-related information and clinical assessments are collected. The team leader takes responsibility for ensuring that the individual, his or her family, and any other significant individuals are invited for the evaluation. The team identifies the life roles, the specific activities engaged in, and any problems the individual has in fulfilling these life roles. The team prioritizes the order in which to address barriers to participation, and a specific plan of action is developed. As time goes on, further assessments should be performed and needs should be noted. The assessment team includes the individual and his or her caregivers as primary members.
Phase 2 Assistive Technology Assessment
Once the team has agreed on a specific plan of action and those things that “must” occur, phase 2 of the assessment process begins. AT devices are tested along with various adaptations, modifications, and placements to ensure appropriate matching of the technology to the individual. Because many devices require extensive training and follow-up, it is essential that realistic information about training and learning time be provided and appropriate resources within the local community be identified. With very few exceptions, the wise course of action involves borrowing or renting the AT device before making a final purchase decision. Consumers and their families should always be informed so that they can make the final decision regarding when and where the equipment will be delivered. AT professionals, in consultation with the physician, should also anticipate future needs, and final decisions should consider both the expected performance and durability of the device.
Writing the Assistive Technology Assessment Report
The evaluation report documents the AT assessment process and must include several components. First and foremost, it is helpful to use layman’s terms to help case managers, educators, and others unfamiliar with ATs understand the process. The report should focus on the funding requested to purchase the technology. It is also extremely important that all components of the AT device be included in the list of recommended equipment because devices are often recommended for purchase as a “system.” Besides purchasing AT devices, paying for the AT services is important to avoid low use or abandonment. Finally, it is also important to include the vendors’ contact information.
Physician Responsibilities (eSlides 19.14 and 19.15)
Prescribing the Technologies
The following items should be considered when prescribing AT devices and certifying medical necessity. The physician must provide evidence of individual medical necessity for the specific AT, and health insurance companies require an “appropriate” prescription that includes mention of the comprehensive assessment process, individual’s motivation, availability of training, and potential functional outcome(s) for the patient.
Documentation in the Health Care Record
In addition to prescribing and certifying medical necessity on various forms, physicians must maintain a system that tracks device performance and maintain complete patient health care records that include details such as the diagnosis, patient’s condition, prognosis, functional limitations, interventions and results, and a list of all assistive devices. This comprehensive health care record supplies the background information needed to substantiate the need for AT devices and services, regardless of the funding source.
Funding Letters of Medical Necessity
Physicians are frequently asked to write “letters of medical necessity” to help ensure that the AT needs of patients are met. These letters should include the diagnosis and functional limitations of the patient. In addition, there should be a statement about the patient’s inability to perform specific tasks, such as activities of daily living, work activities, or functional walking.
The letter should also include a paragraph stating why the equipment is necessary and a rationale for choosing this specific equipment. It also requires a description of the specific equipment features and listing of all the required components.
Funding Assistive Technology
Funding sources for AT devices and services are private or government medical or health insurance and the coverage is based on existing laws and regulations.
The five steps in developing a funding strategy are as follows: (1) surveying the funding resources available to the individual, (2) identifying various funding sources for various steps in the AT intervention, (3) preparing a funding plan with the patient and family members or advocates, (4) assigning responsibilities to specific individuals for the funding of each step of the AT intervention, and (5) preparing the necessary written documentation for the funding source so that there is a record in the event an appeal is needed.
Conclusion
The growing culture of inclusion is changing traditional concepts about disability and impairment. Future research regarding AT should include opinions of individuals with disabilities and their families and use mainstream technologies to provide more opportunities for participating in activities of daily living.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
