Service Delivery for Assistive Technology

Primary reason why we use assistive technologies

“In designing assistive technology systems, we build on the skills of the user and provide assistive devices that augment or replace functional limitations”

• building on the skills they can do, not what they can’t do

• also, don’t focus on the technology

3 things you need to know when designing/evaluating for an AT system

• What can be done (skills)

• What cannot be done (limitations)

• What will be done (motivation)

Principles of Assessment and Intervention

• Considers all components of the HAAT model

• Is primarily used to enable performance not to rehabilitate or remediate

  • e.g., not improving ROM, improving a functional outcome (e.g., dressing)

• Is ongoing and deliberate

• Requires collaboration

• Involves gathering and interpreting data

  Conduct assessment and intervention in an ethical manner

• Conduct intervention in a sustainable manner

• AT assessment and intervention are informed by evidence

Why Evaluate?

Foundational knowledge to successfully carry out basic evaluation

1. What knowledge is brought to the table?

   1. don’t give our knowledge you don’t know (e.g., whether an insurance company will reimburse a specific AT)

2. What technology is even available?

3. What are different strategies for the AT use?

   1. e.g., using a speech therapist in addition to their speech communication device

4. What related services might be needed?

5. What are the sources of funding?

6. Who/what are the resources available regarding the equipment and its use?

Overview of the Assessment Process

• Referral and intake

• Initial Evaluation

  • Needs Identification

  • Skills Evaluation

    • Sensory

    • Physical

    • Cognitive

    • Language

  • Device Characteristics (trial and data collection)

• Recommendations & Report

• Implementation

  • Order & set-up

  • Delivery & Fitting

  • Training

• Follow-up

  • Maintenance and repair as needed

• Follow-along

  • Reevaluate, maintain, repair

Referral and Intake

• Purpose

  • Gather preliminary information on the consumer

  • Determine if there is a match between the needs of the consumer and the services that can be provided by the ATP

  • Tentatively identify services to be provided

• Criteria for service

Needs Identification

• Background, needs, and goals

• Personal information

• General history (including past technology use/experience)

• Consider any third parties involved

  • e.g., family members, caregivers, work companies, insurance, etc.

• Possible outcomes of screening

• Can use interviews, written questionnaires, or standardized tools

• The team must address the following

  • 1. What does the user want to accomplish as a result of using the AT?

    • client-centeredness!

  • 2. In what environments (context) will the activity take place?

  • 3. How will the user and the team involved determine whether progress is being made or goal achieved?

Skills Evaluation

• Must assess the potential user’s functional abilities as well as their limitations

• Must have an understanding of the environment in which the individual will participate in the task

• Ask the ?’s:

  • What skills are needed to do the activity?

  • What skills does the person have to do the activity?

  • Where is the activity done and under what conditions?

Functional Vision

• Visual acuity: aspects of the visual system related to focusing an image on the retina and interpreting it (size, contrast, spacing)

  • e.g., w/ Snellen eye chart

• Visual field: range of vision, central and periphery; normal is

  • 70 degrees nasally (move vertical pen inwards towards someone’s nose)

  • 104 degrees temporally

  • 60 degrees above horizontal (move horizontal pen up above nose)

  • 75 degrees below horizontal (move horizontal pen down below nose)

• Visual tracking and scanning: ability to follow a moving object (track) and ability to locate different parts of a stationary image (scan)

  • Conjunctive (both eyes moving together)

  • Disjunctive (eyes not moving together)

• Visual contrast: differentiate a figure from its background (i.e., foreground vs background)

• Visual accommodation: change in the focal point of the eye; closest point an object can be focused on is called the “near point” (i.e., ask at what point does it stop being clear?)

Visual Perception

***not an actual problem with their vision, but more so how they perceive their vision

• “The process of giving meaning to visual information”

• Depth perception, spatial relationships, form recognition/constancy, figure-ground discrimination

• Standardized testing such as the MVPT, TVPS

  • Motor-free Visual Perception Test

  • Test of Visual Perception Skills

• Accommodations can be made, such as changing the visual contrast, increasing the space between items, and simplistic b/w icons

Auditory

***important to see if people aren’t attending to you b/c of auditory vs cognitive problems!

• Auditory thresholds include both the amplitude and frequency of audible sounds

• Amplitude is measured in decibels (dB)

• Typical range of frequencies that can be heard is 20 to 20,000 hertz (Hz). However, the ear does not respond equally to all frequencies in this range

• A combination of frequency and amplitude determines auditory threshold

• If suspected impairment, evaluation by an audiologist

• Special consideration to devices that provide auditory feedback

Tactile

• Important to consider in the case of seating/positioning, tactile control interfaces, touch as an aid to low vision/hearing

• 1-2 point discrimination: ability to detect a single tactile stimulus from two points that are applied simultaneously

• Perception of light touch versus deep pressure: ability to detect a stimulus that is featherweight to deep pressure

• Perception of temperature: detect hot and cold

• Joint position sense (proprioception): position of a joint or limb in space

• Location of tactile stimulation (i.e., where they were touched)

• It is important to consider the relationship between motor and sensory systems

Physical

• Overall goal: determine the most functional position for the individual and evaluate ability to access a device

• Step 1 Positioning – Address any concerns in this area first; identify position that optimizes ability to operate device

  • 90-90-90 is the best position

• Step 2 Potential sites of control – Evaluate functional movement, ROM

• Step 3 Select interface

• Step 4 Comparative testing of interfaces

  • e.g., AT switch can be small if you are using your finger; AT switch must be big if you are using your knee

Evaluation/Things to consider

• Range of motion

• Muscle strength and endurance

• Gross motor movements

• Fine motor movements

• Reaction time

• Effect of:

  • Primitive reflexes

  • Righting reactions

  • Equilibrium reactions

  • Muscle tone

Comparative testing

• After selecting potential control interfaces- trial and gather data as to effectiveness in areas of speed/accuracy

• Compare data between interfaces to determine what is potentially most effective

• Computer assisted assessments can be a valuable tool here

Perception

• Perception adds meaning to sensory data

• All sensory systems have both physical and perceptual thresholds (minimum level of input)

• Figure-ground perception

• Auditory localization

• Auditory figure-ground localization

• Kinesthetic perception

• Tactile perception

Cognition

• Referring to functions such as orientation, attention (selective, sustained, divided), memory (working and long-term), and executive functions (judgment, insight, problem solving, planning, organization, monitoring)

• Usually assessed through clinical observation throughout the evaluation

• Especially important in pediatrics, TBI, aging population, where changes in cognition are most likely to be present

• populations that cogntiive assessments are very important for (insurance ocmpanies require!!)companies

  • kids

  • TBI

  • when people are aging

Language

• Receptive and expressive abilities, categorization, sequencing, use symbol systems, combine language elements into complex thoughts (e.g., taking words and putting them into coherent sentences), matching, pragmatics, and social communication skills (e.g., recognizing when to say things vs not)

• Thorough evaluation is done when considering AAC (Augmented and Alternative Communication)

• Also considered in mobility systems, hearing impairments, ECU

Also evaluate

• Past experience with assistive technology

• Context evaluation

  • Physical

  • Social

  • Cultural

  • Institution

  • Home evaluation – if possible (not always possible, depending on who is paying for the evaluation)

Matching system characteristics with user needs/abilities

Use the HAAT Model as a structure

Thoughts on trial periods and data collection

• minimum of 2-week trial period to see whether it’s compatible/good for a client

  • Loaner devices

  • Does device do what you set out to accomplish?

  • Data assists in the funding process

  • Can be included in recommendations/report

Recommendation and Report

***insurance companies don’t want to pay!!; they will always be asking for more information

• Summarize the information gathered during the evaluation and suggest a design for the AT system

  • you will need to write insurance a letter and fight for a device

• All team members should review the assessment and come to a consensus

Implementation Phase

• Obtain funding

• Ordering and set-up

• Delivery and Fitting

• Facilitating performance through training, written instructions, and performance aids

  • create educational information for your clients

Follow-up and Follow-along

• Follow-up – activities that occur immediately after delivery of an AT system and that address the effectiveness of the device, training, and user strategies

• Follow-along – activities that take place over a longer period addressing factors such as changes in needs or goals, availability of new devices and other concerns

• Repair – action to correct a problem in a system

• Maintenance – systematic set of procedures that is aimed at keeping the device in working order

Evaluating System Effectiveness & Outcomes

• Effectiveness (does it work)

• Efficacy (produces the desired result)

• Availability (is it reaching those who need it)

• Efficiency (is it worth it)

• Satisfaction with the device

• Subjective contribution of the device to the client’s well-being

How do you measure AT outcomes?

• Single-subject design

• Quantitative

• Qualitative

• Other???

• Types of measures

  • Outcome measures

  • Functional performance measures

  • User satisfaction measures

  • Quality of life measures

Instruments

• Clinical and Functional Outcomes

  • Occupational Therapy Functional Assessment Compilation Tool (OT FACT)

    • computer assessment that looks at how AT contributes to someone’s occupational performance

    • good for making a good case for why an AT may be needed

    • looks at functional outcomes

  • FIM (Functional Independence Measure)

    • one of the most commonly used occupation measures

    • looks at functional outcomes

• User Satisfaction Measures

  • Canadian Occupational Performance Measure (COPM)

    • looks at user satisfaction

  • Quebec User Evaluation of Satisfaction with Assistive Technology (QUEST)

    • looks at user satisfaction

• Quality of Life Measures

  • Psychosocial Impact of Assistive Devices Scale (PIADS)

  • Matching Person and Technology (MPT)

Team or Individual Assessment

• Team

  • More expertise

  • Many points of view

  • Includes the person & caregivers

• Individual

  • Less time

  • May have a specific area of expertise