Outline
VA Polytrauma Assistive
Technology Labs: Focus on AAC and
Electronic Cognitive Devices
• VA Polytrauma System of Care
• University of Pittsburgh consultant
• AT Labs at the VA Polytrauma
Rehabilitation Centers
• Andrew Jinks, MA CCC-SLP, ATP
– University of Pittsburgh, Pittsburgh, PA
• Micaela Cornis-Pop, PhD CCC-SLP
– Project milestones
– Electronic cognitive devices
– AAC devices
– Richmond VA Medical Center, Richmond, VA
• Telina Caudill, MS CCC-SLP
– James A Haley VA Hospital, Tampa Bay, FL
• Richard Schein, PhD
– University of Pittsburgh, Pittsburgh, PA
Integrated System
Polytrauma System of Care
• Goal of system was to match geographic need of
Veterans (and Servicemembers) with clinical expertise.
Polytrauma Centers (4)
Regional referral centers
– VA uses extensive GeoID mapping of all Veterans
– Most Veterans are from “rural” areas (>30 miles) of
major cities
Polytrauma Network Sites (22)
VISN level referral sites
• Through MOA, VA may provide Servicemembers with
rehabilitation services for TBI, SCI, Amputation and
Burns.
Polytrauma Support Clinics (85)
Facility level teams
• Only 40% of eligible Veterans utilize VA services.
• All OEF/OIF Servicemembers are eligible for care for 5
years after service.
Polytrauma Points of Contact (43)
Referral and care coordination
VHA Polytrauma System of Care
Polytrauma Rehabilitation
Centers
• Four Level 1 medical centers providing the highest echelon of
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Sep 9, 2009
comprehensive medical and rehabilitative services (inpatient and
outpatient) for the most complex and severely injured:
– 12-18 inpatient bed units providing acute interdisciplinary
evaluation, medical management, and rehabilitation
– 10 inpatient bed residential Transitional Rehabilitation Program
– Emerging Consciousness Program
– Assistive Technology Lab
– Polytrauma Telehealth Network
National VA leaders in polytrauma / TBI providing consultation,
medical education, research, and program development for system
of care
Accredited by CARF for inpatient TBI and general rehabilitation
Collaborate with DVBIC and national TBI Model Systems project
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Polytrauma Rehabilitation
Centers
Richmond
Tampa
Polytrauma Network Sites
• 22 regional Level 2 medical centers providing full range
of comprehensive follow-up medical and rehabilitative
services (inpatient and outpatient) for patients
recovering from polytrauma and TBI (1 per VISN, and
San Juan):
– Develop and support patient‟s rehabilitation plan through
comprehensive interdisciplinary, specialized team
– Serve as resource and coordinate services for TBI and
polytrauma across VISN (VA, DOD, private sector)
• VISN leader for polytrauma/TBI consultation, education,
monitoring outcomes, and program development
• Accredited by CARF for inpatient general rehabilitation
Palo Alto
Minneapolis
Polytrauma Support Clinic
Teams
Polytrauma Points of
Contact
• 85 Level 3 medical centers with dedicated outpatient
interdisciplinary teams of rehabilitation specialists
• Designated at 43 medical centers without specialized
rehabilitation teams
• Provide specialty rehabilitation care closer to home
• Designated VA primary care staff member
knowledgeable in the Polytrauma System of Care
– Evaluate and develop individualized treatment plan
– Provide interdisciplinary rehabilitation care and long-term
management of patients with rehabilitation needs
– Coordinate clinical and support services for patients and families
• Conduct comprehensive evaluations of patients with
positive TBI screens, develop and implement
rehabilitation and community re-integration plans
• Coordinate case management and referral within
Polytrauma System of Care
• Knowledgeable of rehabilitation services provided
within local community, and facilitates referral for such
services as necessary
Assistive Technology Centers
of Excellence
• Partnership between the VHA and Academic
community (University of Pittsburgh)
• Established 4 COE across VA – 5/10
– In-person evaluation and training
– Telemedicine evaluation and consultation
– Teleconference and in-person training of staff
• Establish AT expertise in each of 22 VISNs by
2011-12
– In-person evaluation and training
• AT resources available to all Veterans
VA PRC AT Labs
Project Overview
Andrew Jinks, MA CCC-SLP
Consulting Speech-Language Pathologist
Richard Schein, Ph.D. VA-PRC
Project Coordinator
Mark R. Schmeler, Ph.D., OTR/L, ATP
Project Director
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Overview
Overall Goal
Support VA, VA Clinicians, Veterans, &
active-duty military personnel
through the appropriate application
of Assistive Technology
Overview
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Continuing Education
Outcome Management System
Product Evaluation
CARF Accreditation for AT
Informatics Infrastructure
3-Year Systematic Plan with Milestones
• Needs Assessment
• Development Plans
– Physical space, training, equipment
– Practice guidelines, documentation,
outcomes
• AT Intervention
• Build Upon Existing Programs
University of Pittsburgh
AT Team
– University of Pittsburgh
• School of Health & Rehabilitation Sciences
– Department of Rehabilitation Science & Technology
• School of Medicine
– Department of Physical Medicine & Rehabilitation
– Subcontractors
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The Ohio State University
Minkel Consulting
Eadvantage
AT Sciences
Center for Assistive Technology
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AT Service Areas
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Wheeled Mobility and seating equipment (WMS)
AAC Devices
Cognitive orthotics and learning technologies
Electronic aids to daily living (EADLs)
Adapted computer access
Adapted driving and vehicle modifications
Adapted recreation equipment
Augmentative
Communication Services
• Evaluations for Speech Generating
Devices
• Augmentative Communication Therapy
& Training
• AAC Consultation Services
Pitt AT Team
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Occupational Therapists - 2
Physical Therapists - 3
Speech-Language Pathologist - 1
Rehabilitation Engineers - 3
Physicians -2
Administrators – 3
Nurse – 1
Information Specialists – 5
Site Visits
• Initial Site Visits to each of the PRCs May-July
2009
• UPITT team consisting of 12 various disciplines
and specialty backgrounds met with
administrative leadership at each of the sites for
a „kickoff‟ meeting to discuss the overview of
project and goals during the needs assessment
• Tour of the facilities included inpatient SCI, TBI,
transitional apartments and individual therapy
clinics
Milestones 1- 3
• Milestone 1: Initialize Project
– May 2009 Management Team - Denver VA Medical Center
– May 2009 Kick-Off Meeting in Richmond, VA
• Milestone 2 & 3: Develop Design and Work Plans
– June/July 2009 Needs Assessment
– Facility Resources
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Identify Current AT Services and Core Areas
Capacities and Preference with Outcome Tools
Resources
Continuing Education
AT Services Focus Groups
• UPITT members split into focus groups with
polytrauma clinicians to gather information
pertinent to the facilities current AT practices.
• Clinicians involved in the following areas
were included:
– WMS
– AAC
– EADLs
-Adapted Computer Access
-Adapted Driving
-Adapted Recreation
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Challenges
Focus Groups cont.
• Key points included:
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Identification of service providers
Identification of client population
Space accommodations
Review of AT devices housed in various
departments
Review of documentation templates in use
Identification of methods for gathering outcomes
Evaluation of standards of practice
Identification of specific education needs
• Information security
• Network security
• Firewalls
• Affects
• Access to online education
• Resources for Telerehabilitation
• Connection of PDAs to network computers,
etc.
Rehabilitation Engineering
Establishment of Teams
• Recommended team composition
– Program Coordinator
– Speech-Language Pathologist
– Physical Therapist
– Occupational Therapist
– Rehabilitation Engineer
– Rehabilitation Technician
 Application of science and technology to
improve the quality of life of individuals with
disabilities
 Rehabilitation Engineering and Assistive
Technology Society of North America
(RESNA) - www.resna.org
◦ Mission: To improve the health and well-being of people
with disabilities through technology.
 Certifications
◦ Assistive Technology Professional (ATP)
◦ Rehabilitation Engineering Technologist (RET)
• Other specialists by consultation
Unique AT Needs of VA
Polytrauma Centers
• Technology or combination of technologies
that best suit the complex needs of the
polytrauma patient
• The polytrauma patient presents with two or
more of the following injuries. It is not
uncommon to treat a patient who exhibits
each.
Polytrauma Patient
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Traumatic Brain Injury
Blindness or low vision impairment
Amputation
Burns
Hearing Loss
Infections
Wounds/pressure ulcers
Paresis
Spinal Cord Injury
PTSD
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Military Culture
Family Support
• Suffering from the loss of brothers in combat
• Transferred to the PRCs, which limits
communicating with and support of their
comrades
• Wish to return to combat with their
comrades
• Young and technologically savvy
• Incorporation of military culture as a
motivational tool and effects on rehab
• Integral member of the rehab team for goal
formation and patient support/motivation
• Families have high expectations and
understandably want the latest advances and
state of the art technology for their loved one
• Families live together on campus. They are
very aware of everybody’s care, therapy and
receipt of technology
• Family involvement facilitates improved
education and carryover of newly learned skills
Range of TBI Severity
• AT consults entered for MCS to High
Functioning TBI patients
• Clinician may follow patient through the
different levels of care from acute
inpatient→transitional→day
treatment→community living (postdeployment OIF/OEF program)
Electronic Cognitive Devices
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iPad or iPod Touch
Smart Phones
Livescribe Smart Pen
Smart watches
Ablelink
PIM Software
ELECTRONIC COGNITIVE DEVICES –
LOW VISION, AMPUTEE AND ALEXIA
• Devices tailored for those with visual, reading and/or
dexterity impairments (i.e., TTS, hands-free voice
recognition, speech/picture/video cues)
– TADI
– Ablelink Pocket Endeavor
– Moshi
– Digital Voice Recorders
– iPhone Accessibility features
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COMMUNICATION APPS
• Proloquo2Go $189.99
– Also available in bundle packages
including device + app
• Voice4U $29.99
– Also compatible with Android
• Speak It $2.49
• SmallTalk for Aphasia FREE
• Locabulary FREE
– Links with GPS for location specific vocabulary
Electronic Cognitive Devices
Electronic Cognitive Devices –
Clinical Practice
Recommendations
• Developed by an interdisciplinary group
of VA SLPs, OTs, and Prosthetics
specialists. Include:
– Specific indications and contraindications
– Processes for prescription and issuance
• Personal, environmental and device factors
– Training content and procedures
– Follow up
– Documentation and data collection
Milestone 5 – Education
4000
Virtual AT Grand Rounds
3500
• Quarterly Webcasts - Sept. 2009
3000
2500
AAC Device
PDA/Smart phone
GPS
2000
1500
1000
500
RESNA ATP Exam Preparation & Training
• March 2010
3-Day Accredited AT Institutes
. May 2010
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FY'08
FY'09
FY'10
Grand Rounds
Example of Virtual AT
Grand Round
• Accessible Video Presentations
– Augmentative Communication
– Rehabilitation Engineering
– Electronic Cognitive Devices
– Tissue Integrity Management
– Spastic Hypertonia
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AAC – The components of:
Aids (Devices)
 A device that can be either:
non-electronic
Low Technology
or electronic
High Technology
for transmitting messages
Andrew Jinks, MA CCC-SLP, ATP
Center for Assistive Technology
University of Pittsburgh
History of AAC
Early Humans
Apple II computer – 1970’s
The Apple II
computer was the
first
microprocessor
designed
specifically for
home use.
used symbols
(cave drawings) to
communicate
Plato refers to
signing by the deaf
Speech Generating Devices (2010’s)
Types of AAC Devices
1) basic picture-message fixed display
2) text-to-speech keyboard spelling
mytobii C12
Saltillo’s ALT-Chat
PRC’s ECO
DynaVox TANGO
Words+
Say-It-Sam
Handheld
3) sophisticated symbolic coding- based devices.
DynaVox
Xpress
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Synthesizers
Mounting for access
 DecTalk – 9 voices (Perfect Paul, Whispering Wendy)
 Types of mounts
 Switch
 Swing-Away
 Folding
 Table top
 Rigid
 Lap tray
 VeriVox (Michael, Sarah)
 AT&T Natural Voices (Crystal, Rich)( Italian, German)
 Neospeech (male/female) Stephen Hawking’s choice
 Acapela (Heather, Kenny) (British, Dutch, Norwegian)
 Real Speak (Samantha, Tom) (20 languages)
 Loquendo (French, Spanish)
Photos from AbleNet, Daessy, & Abledata websites
Selection Techniques
 Eye gaze
 Brain Controlled Interface
 Eye gaze communication board.
- Image created by University of Pittsburgh
Milestones 6 & 7
Challenges for Augmented Communicators
 Rate of communication
 Artificial speech
 Pragmatic communication problems
 Acceptance of use of SGD
 Coding of messages
 Access techniques
 Cognitive load
• Milestone 6: Standardized AT
Procedures
– Standards of Practice
– Documentation & Electronic Templates
September 2010
• Milestone 7: Consultation Services
– In-Person/On-Site – March 2010
– Telementoring
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ECD Documentation
Template
AAC Practice Guidelines
• American Speech-Language Hearing
Association
– Augmentative and Alternative Communication
Knowledge and Skills for Service Delivery
(2004)
– Technical Report (2004)
– Position Statement (2005)
• Veterans Administration Prosthetics and
Sensory Aids Service
• Assessment Variables
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CLIENT BACKGROUND
EXISTING DEVICES
BODY SYSTEMS
ACTIVITY
CLIENT GOALS
ENVIRONMENTAL USE
- TRIALS
- OUTCOMES
- RECOMMENDATION
- PLAN
– Speech Devices AAC Systems (2004)
Milestone 8
• Evaluation of AT Devices
– Develop AT Evaluation Model
• (Batavia and Hammer, 1990)
– Conduct AT Product Evaluations
– Disseminate Updates in IT formats
Milestone 9 – Outcomes
– Identify AT Outcome Measurement Tools
March 2010
– Barriers to Implementing Outcomes
– Test-Pilot Tools – September 2010
– Develop Outcome Data Collection
Procedures
– Data Analysis Models – October 2010
Outcome Measures
• PIADS – Psychosocial Impact of
Assistive Devices Scales (Day & Jutai, 1996)
– 26 item rating of how using an assistive
device may affect a user
– Ratings of: competence, happiness,
efficiency, usefulness, sense of control,
ability to adapt to ADL‟s, etc.
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Outcome Measures
• QUEST – Quebec User Evaluation of
Satisfaction with Assistive Technology
(Demers, Weiss-Lambrou and Ska, 2000)
– 12 satisfaction ratings of device and
service
– Dimensions, ease in adjusting, durability,
repairs and servicing, follow-up services
Milestone 13 – Information
Technology
Milestone 12 – CARF
– Design Plan for CARF AT Accreditation
October 2010
– Work Plan for CARF AT Accreditation
– Quality Assurance (i.e. organization
performance and quality services provided)
– Mock CARF AT Surveys at 4 PRCs
ICAT-Workbench Homepage
• ICAT-Workbench
– Internet-based Informatics Infrastructure
– External Resource Complementing Existing VA
Procedures
– Interlink Multiple Resources Into Single Portal
• Education
• Standardized Assessments, Treatment Plans, &
Workflow
• Coverage Policies & Guidelines
• Outcome Measurement
Therapist Workbench:
Videoconference &
Online Documentation
Continuing Education
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AT Device Reviews
AT Prototype Online Outcomes
Database System
AT Prototype Online Outcomes
Database System
Future Plans
• Fully functional CARF Accredited
Assistive Technology Labs that have
consistent capabilities at the 4 PRCs
• Overlap to other than Polytrauma within
the PRC
Future Plans
• Outreach, Collaboration, Consultation,
Mentorship with other VA Medical
Centers
• Possible migration and maintenance of
information by the VA sites or ongoing
services by University of Pittsburgh
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