Getting To The “So What?!” Of Ruling Out Or In AAC Methods

In an attempt to secure funding for an SGD, an SLP may be met with a deferral or denial from a funding source, where the information provided somehow did not meet the requirements of the funding source. These deferrals or denials are tantamount to the funding source saying, "You provided me with some information but not enough to convince me of the medical necessity of this device for the client. So what (more can you tell me)?" For the purposes of this article, we’ll call that the funding source "so what" factor.

• It may be that the language used in the report was not specific.
• The report may have lacked data and evidence to support the medical necessity of the device.
• Or, it’s possible that information in the report lacked continuity or congruity with other evidence provided in other areas of the report (i.e., the report recommends a device with access to unlimited language to allow the client to generate spontaneous novel utterances, but the cognitive and language sections of the report don’t provide evidence that supports that the client needs a complex device with access to unlimited language).

When met with a deferral or denial, it’s incumbent upon the SLP to ask:

• What more could be said to answer the funding source’s questions and quell their reservations about funding this device?
• What further information can be provided to neutralize the funding source "so what" factor?

This article will provide examples of report language that is not specific, lacking data or evidence, or is provided with little congruence or support from the remainder of the report. Each example will be followed with bulleted advice or ideas to remedy the language to make it more funding-ready or compliant, and work toward eliminating the underlying funding source question of "so what?"

Keep in mind that the best defense is a good offense – having a strongly written initial report will hold more weight than having to add information in an appeal or addendum after submission. All of the tips that follow can and should be implemented in your initial report. However, if your initial report is deferred or denied, these issues can be addressed in an appeal.

"X has trialed (AAC METHOD) in the past with limited progress or minimal success."

So what?!

Discussion: The examples above are non-specific and lack detail or evidence to support the statements made. The discussion of the AAC method trialed in the past should be expanded to included reasons why the method was not effective or successful and did not meet the client’s daily and medical communication needs.

The following are ideas of language that could be added to the examples, to eliminate the "So what?" factor:

• Inability to use these systems/communication methods to generate spontaneous, novel utterances
• Too cumbersome to manage independently
• Picture vocabulary not robust enough (core words hard to depict so lots of focus on nouns)
• Works well for requesting, but difficult to expand to other language functions including commenting, directing, protesting, negating, asking questions, etc.
• Reliance on communication partners who understand the modality (makes it a dependent method)
• Not fast enough
• No auditory feedback necessary for x to establish cause and effect
• Client does not have fine motor skills or manual dexterity to formulate signs, point to or pick up symbols, or produce written letters

"X has trialed (AAC METHOD) but requires maximum support to use it. X cannot use (AAC METHOD) independently."

So what?!

Discussion: The example above is not detailed enough. The discussion of the client’s previous use of the iPad + app should be expanded to include a detailed narrative of the client’s use of this alternative system and the reasons it was not successful and did not meet the client’s daily and medical communication needs. Statements like, "not able to use it independently," or "with maximum support" should be given context through a thorough narrative discussion of the client’s use of this system and reasons why it failed to be successful. What is keeping/hindering the person from accessing/using the device independently with minimal support?

• Fine motor skills (doesn’t allow alternative access or touch accommodations such as keyguard)
• Distractibility by other features/functions available in the device
• Organization/layout of the vocabulary (i.e. category or page-based)
• Motivation (static displays aren’t as motivating as dynamic ones)
• Ease of use or ease of getting to words you want to say (PECS symbols falling out, never put back in the same place)

Common reasons and language used to support that a commercially available iPad + app fails to meet a client’s daily and medical communication needs:

• Not defined as DME by the NCD guidelines
• Not in X’s best interest as there is no repair or replacement coverage, no training or implementation support
• X does not have his/her own tablet or tablet is shared by family and used for recreation
• Requires guided access
• Not dedicated and can be used for nonmedical purposes which is why it isn’t reimbursed as DME allows access to convenience and luxury features such as games and videos which cause distraction and confusion in understanding whether the device is to be used for communication or leisure

In the example above, statements like, "not able to use it independently", or "with maximum support" should be given context through a thorough narrative discussion of the client’s use of this system and reasons why it failed to be successful. Did the client struggle because:

• iPad allows access to convenience and luxury features such as games and videos which cause distraction and confusion in understanding whether the device is to be used for communication or leisure
• Lack of training available to use and implement the system
• Why was maximum support required? Was there concern over the durability of the iPad and therefore client required an adult to hold/carry the device to reduce the risk of dropping or damaging the iPad? Expand the narrative to make sure it provides the answers to the funding source reviewer’s potential questions.

"Although X has demonstrated the ability to independently use (AAC METHOD), it is too limiting and will not meet his/her high potential for growth because it does not offer a full, robust language system."

So what?!

Discussion: In the examples above, they all indicate or imply that a no-tech or low-tech option would not meet the client’s communication needs because they are too limited, and don’t meet the client’s needs access to more robust language. Some things to consider to make sure that the information in the report supports these claims:

• The other areas of the report, including the receptive and expressive language evaluation sections and the cognitive evaluation section, must support that the client has demonstrated need for a robust communication system
  • If you state, "X’s vocabulary size is too large to accommodate in a low-tech system", then it is imperative that you give evidence of the size of the client’s vocabulary
  • state your evidence and how you evaluated the client’s vocabulary size (e.g. has he client used PECS or a previous SGD from which basic vocabulary size can be estimated?)
• Use Brown’s Language Stages or other recognized metrics/research/citations to support that the client’s language needs far outpace what a no-tech or low-tech system can support
  • Stage 1 of language development continues until there are approximately 50-75 single words used expressively. At that point, we begin to combine words into 2-word phrases. Using no and low-tech AAC options (sign language, PECS, low-tech E2506 devices) it would be difficult to progress XXXX’s language skills from using a handful of single words to combining them so that she can then move in to Stage 2 of Brown’s Language Stages. Stage 2 proceeds to over 200+ individual words.
  • No-tech systems such as a PECS book or communication board, and low-tech E2506 devices, such as the GoTalk, TechSpeak, Smart128/VSD do not have the programming capacity to allow for this natural expansion of language through Brown’s documented language stages. Therefore, it would be impossible for XXXX to progress with language development if the tool she’s using doesn’t allow for that expansion.

Ruling out PECS, picture symbols, books and boards (E1920), and Low-tech/mid-tech E2500-E2506 devices (such as GoTalk or AMDi Smart 128):

• XXXX is non-verbal and his expressive speech skills do not allow him to functionally meet the majority of his communication needs without augmentative communication. XXXX is currently using a manual picture exchange communication book (PECS). This book has been adequate for XXXX to learn the basics of how to communicate his wants and needs; however, at this point his picture PECS book is limiting his continued communication development. XXXX is ready to expand his vocabulary as well as the types of communication functions he uses. XXXX is combining a picture of "I want" and a picture of a desired item into a 2-word phrase. Students move into Brown’s stage 2 when they start combining words into 2-word phrases. XXXX‘s ability to combine 2 symbols into a phrase indicates that he is moving into Brown’s stage 2 of language development.
• The current or reasonably foreseeable size of the client's functional vocabulary and language development as indicated by the client moving into Brown’s Stage 2 of language development, is evidence that this physical and functional limit of an E1920 communication system (such as PECS, Picture Symbols and Books and Boards) or E2500-E2506 (Such as the GoTalk or AMDi Smart 128) digitized device has been surpassed, and therefore, an SGD in the E2510 category that produces synthesized speech and has a touch screen is indicated as necessary for this client’s use.
  • The physical and/or functional limitations of picture exchange such as PECS, communication boards and books (E1920 category); and digitized speech-output devices (E2500-E2506 category) for the client’s use and continued language development are as follows: As indicated in the article PECS: Potential benefits and risks., January 2001 The Behavior Analyst Today 2(2) DOI: 10.1037/h0099924, by Andy Bondy, one of the developers of the PECS Communication System, "In such cases [clients able to use more than 120 cards] changing to an electronic system that can accommodate more symbols would be appropriate....". Per this article, it is reasonable to expect that clients with vocabularies that exceed 120 - 130 words or for whom growth of vocabulary is reasonably foreseeable to be larger than 120-130 words, can rule out these non-voice output or digitized speech output communication aids as not appropriate based on the current or reasonably foreseeable size of the client's functional vocabulary.

"Parent/Teacher/Therapist reported successful use of an iPad with (RECOMMENDED LANGUAGE SYSTEM) in the home/school/clinic environment and thus requested that purchase of a dedicated speech-generating device be pursued."

So what?!

Discussion: Funding sources are looking for empirical data, and will not put much weight on a parent opinion, desire or request for a device that isn’t supported by data. It is important to make device recommendations based on data showing that the client can use the recommended device and that the recommended device is the least costly equally effective alternative that will meet the client’s needs.

The type of information that funding sources are looking for includes:

• All lower-cost alternatives, including no-tech, low-tech, mid-tech, and commercially available iPad/Tablet + app options have been ruled out for the client’s use – provide a detailed and systematic categorical rule-out of all the other communication system options.
• Provide a narrative describing the device trial (link to blog article on Consider, Try, Trial – What’s the Difference?)
  • Discuss the device, vocabulary, and accessories (e.g., keyguard, touchguide, switches, Look, NuPoint, etc.) that were trialed.
  • Discuss the length/duration of the trial period. Also discuss amount of time client used the device daily (e.g. client used the device to communicate on and off throughout his day – daily average usage of 6.5 hours
  • Discuss the communication environments and partners the client used the device with (where and with whom the device was used)
  • Discuss the communication and language task(s) evaluated (such as initiating communication, responding to questions, making requests, effectively expressing wants, needs, feelings, and ideas, participating in conversations, and asking basic/functional questions)
  • Discuss the type and number of symbols/pictures and/or words used with each device trial
  • Discuss extent to which the client used the device independently
• Provide as much data/evidence as you can from the trial that shows/supports the need/medical necessity of the recommended SGD and why it is the best choice to meet the client’s daily and medical communication needs. You can collect data using data collection sheet such as the one linked here:
  • Trial Data Collection Sheet

Justification for the device you’re recommending

"The (RECOMMENDED AAC DEVICE) was selected due to features or unspecific evidence/data: such as its weight and size and ability to independently access and carry the device, or supported by undefined statements of evidence."

So what?!

Discussion: Funding sources are looking for empirical data. It is important to make device recommendations based on DATA showing that the client can use the recommended device and that the recommended device is the least costly equally effective alternative that will meet the client’s needs. The examples above are lacking detail and evidence that supports the assertions made in the statements about the client’s use of the device, or they are making recommendations based on broad features or unspecified statements that are put forth as evidence. It is imperative that the SLP put context to the statements made in the narrative, and provide DATA and evidence that supports that the recommended device is the best choice and the least costly equally effective alternative to meet the client’s needs. The SLP must show that the client can use the recommended device and it’s the best choice to meet the client’s needs.

To make a stronger justification for the recommendation of the device it is necessary to provide the empirical data the funding source is looking for that proves that the client can use this level of device. The following are some ideas:

• Include example utterances from the client’s trial of the device – if you state he added 10 core words, then provide a list of those words and compare to where he started before the trial of the device. Or if the client is putting 2-3 word utterances together, give examples of the utterances the client generated (as well as define their communication partners and communication environments – with who and where did the client use the device).
• If the client used the device in multiple environments, define these. If the client used the device in various activities, for various communication functions, define and describe these.
• Statements such as "increased expressive language skills", should be defined and given context. Compare the client’s performance using the trial device to their previous expressive abilities without the use of the device.
• Features are important, but not the only justification! Need to prove that there’s more to it than this. Explain why the features are important and give examples of how the meet the client’s needs. However, it’s important to also support this with data/evidence that show that the client can use the device (give examples of utterances generated, communication partners and environments in which the client communicated with the device)
• Further ideas to illustrate the trial data: Provide a data chart (Trial Data Collection Sheet) as well as a narrative describing the device trial that includes as much data/evidence as you can from the trial illustrating the medical necessity of the recommended SGD and why it is the best choice to meet the client’s daily and medical communication needs (the data chart should include communicative function, utterances produced, communication partners, communication environments, level of prompting/support needed)
  • Discuss the device, vocabulary, and accessories (e.g., keyguard, touchguide, switches, Look, NuPoint, etc.) that were trialed.
  • Discuss the length/duration of the trial period (e.g., 3/1/2021 – 4/1/2021). Also discuss amount of time client used the device daily (e.g. client used the device to communicate on and off throughout his day – daily average usage of 6.5 hours)
  • Discuss the communication environments and partners the client used the device with (where and with whom the device was used)
  • Discuss the communication and language task(s) evaluated (such as initiating communication, responding to questions, making requests, effectively expressing wants, needs, feelings, and ideas, participating in conversations, and asking basic/functional questions)
  • Discuss the type and number of symbols/pictures and/or words used with each device trial
  • Discuss extent to which the client used the device independently

– Beth Studdiford, M.S., CCC-SLP. Read additional articles by Beth.