SAMPLE OHIO AAC MEDICAID EVALUATION
1. Recipient’s Background Information
Recipient’s biographical information (name, address, phone, DOB, etc.):
Medical diagnoses AND speech/language diagnosis (including specific description of
communication disability):
AAC USER was born three weeks premature and has been identified as having Down Syndrome
and a heart defect. He was in the Intensive Care Unit for eight days. AAC USER had open heart
surgery when he was one year old and continues to be monitored. PE tubes were placed around
two years old. Additionally, AAC USER has a severe receptive/expressive language delay and a
diagnosis of Apraxia, making his speech extremely difficult to understand at times.
Significant medical information/medications:
AAC USER requires over the counter medication to help regulate his sleep.
Medications: Melatonin, Lactulose, multivitamin, Carleson for Kids Norwegian Cod Liver Oil
Allergies: None
Medical Prognosis: The prognosis for speech improvement is guarded.
Vocational/educational status:
AAC USER attends xxxx City Schools and receives occupational, physical and speech therapies
at school. He receives additional weekly physical and speech therapies at the xxxx Medical
Center. He has received speech therapy at xxxxx since February of xxxx. He receives additional
occupational therapy through xxxxx Therapy.
Residential setting:
AAC USER currently resides at home, with his parents and two siblings. Parents are concerned
that AAC USER can not express his everyday wants and needs. He is very clever and makes
daily novel comments and requests. He uses some sign language to comment, however his
comments and ideas are well beyond the capabilities of his fine motor signing abilities. Both he
and his caregivers are becoming frustrated with his inability to communicate complex ideas.
Social history and emotional status as related to communication: AAC USER is a pleasant and
social child who enjoys interacting with others. Due to his many failed communicative attempts,
however, he can become frustrated and at times will become aggressive (i.e., hitting, tantruming,
throwing objects) when his verbal and signing attempts are not correctly interpreted on his first
attempt.
2. Speech and Language Status
Prognosis for speech: i.e., poor, fair, guarded, etc.
Articulation/Oral Motor: AAC USER has a severe to profound oral motor and articulation
deficit. He displays decreased lingual and labial control and coordination. He is unable to
lateralize and elevate his tongue. He also displays a forward tongue placement at rest. He
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receives therapy twice a week at the xxxx Children’s Medical Center focusing on oral motor
skills and speech production. Progress has been slow and has hindered AAC USER’s ability to
grow and develop expressive language skills. Prognosis for clear and intelligible speech is poorfair.
Language skills (expressive and receptive)
Receptive Language: At AAC USER’s last speech and language evaluation on x/x/xxxx, he
presented with a severe receptive language deficit. On the Preschool Language Scale-4 (PLS-4),
AAC USER achieved a standard score of 67, percentile of 1, and age equivalent of 2 years 9
months. AAC USER had difficulty following 2-step commands without cues, understanding
pronouns, understanding negatives in sentences, making inference, and identifying categories of
objects in pictures.
Expressive Language: Also in February of xxxx, AAC USER presented with a severe expressive
language deficit. On the PLS-4 he had a standard score of 57, percentile of 1, and age equivalent
of 2 years 4 months. AAC USER was unable to express plurals, does not combine 3-4
words/signs, use VERB+ing, tell how objects are used, use possessives, or answer questions
logically.
Prognosis for written communication: (You may choose to have OT provide this information if
desired.)
Cognitive status (include developmental and intellectual age or range):
The focus of the assessment of AAC USER’s cognitive skills was to evaluate the following skills
which relate specifically to the use of a SGD: categorization, picture association, memory and
teachability of new concepts. AAC USER’s cognitive skills appear to be delayed for his age.
AAC USER demonstrated comprehension of picture-object association, cause-effect use of SGD
to request desired items and remembered where objects were located given several models. He
did not appear to readily understand categories. After completing an activity with toys, AAC
USER was prompted to “find the toy page,” but was unable to find the “toy” symbol to navigate
to the corresponding page.
On x/x/xxx, Dr. xxxxx tested AAC USER with the Leiter International Performances Scale
Revised, a non-verbal measure of intelligence. Results indicated a mild delay in functioning
when verbal demands were removed.
3. Motor, Postural, and Mobility Status (Evaluated by a licensed occupational therapist and/or
licensed physical therapist.)
• Statement of mobility status
• Information regarding optimal positioning and mobility as related to pelvis, trunk, upper
extremities, head position and control site
• Integration of mobility and positioning with the SGD
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4. Sensory Status
Visual abilities
Auditory abilities
AAC USER is nearsighted and wears glasses. His hearing was tested on x/x/xxxx and indicated
that ear-specific speech reception thresholds were within normal limits in the right ear and mild
in the left ear. A borderline-normal response for speech awareness was noted in the left ear. Ear
specific responses to tonal stimuli were within normal limits from 500-4000 Hz in the right ear
and mild at 500, 2000, and 4000 Hz in the left ear.
5. Current Communication Status and Limitations
Description of communication behaviors and interaction skills
AAC USER uses his signs for pragmatic functions such as labeling a limited number of nouns
and actions, requesting nouns, making choices and responding to greetings and questions. He
displays appropriate eye-contact. AAC USER uses approximately 150-200 signs to express his
wants and needs. While AAC USER’s family understands his sign language, his signs are not
functional and do not allow him to get his needs met at school, in the community, or with
medical professionals. AAC USER appears to have the vocabulary skills and sentence
formulation skills appropriate for a 2 ½ year old.
Description of current SGD (is applicable): n/a
Limitation of current communication behaviors: Although AAC USER does have an expressive
vocabulary of 150-200 manual hand signs, his fine motor skills often make it difficulty for those
who are not familiar with AAC USER to correctly interpret. Additionally, when in the
community, many listeners are not familiar with sign language and therefore cannot
communicate with AAC USER appropriately.
Emotional status as it relates to communication: AAC USER often becomes frustrated when his
communication attempts cannot be understood verbally or via sign. This behavior has, at times,
turned aggressive with hitting and throwing of objects.
6. Communication Needs Assessment
Include information on each area listed of the below:
Communication partners (i.e., AAC USER communicates with his family, with peers and
teachers, with people in the community, and with his team of doctors and therapists.)
Conversational and written communication needs (i.e. AAC USER and his family have become
frustrated with his inability to express himself effectively. AAC USER needs to be able to
effectively communicate wants/needs, thoughts and feelings as well as questions. He also needs
a way to communicate illnesses or discomfort to his caregivers and medical professionals more
clearly and explicitly. He needs to be able to communicate more effectively in order to make
and maintain social relationships in school and home and to enjoy social interaction. He needs a
speech generating device that will meet these communication needs.)
Message needs (pragmatics) (i.e., AAC user needs a system that promotes more than just
communication of basic needs. He/she needs an SGD that promotes independent conversation
and interactive communication with others and is useful across all the environments in which
he/she participates. All pragmatic language functions need to be accessible. These include:
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requesting actions/objects, commenting, directing others, signaling for help, greeting, protesting,
asking questions and sharing information with listeners.
Vocabulary (semantics) (i.e., AAC user needs a system that has access to core and fringe
vocabulary representing all parts of speech (i.e., nouns, verbs, adjectives, pronouns, prepositions,
conjunctions, determiners, question words, grammatical word endings) so that generative,
independent language can be easily created.
Communication environments (i.e., home, school, community, work, phone, computer based
communication [including email communication], etc.)
Integration with other technology (i.e., It is important for this AAC device user to purchase a
SGD that is capable of interfacing with a computer and/or USB memory stick so that written
work such as school assignments, speeches, and notes to a physician can be easily transferred
and printed out if needed. This AAC device user would also benefit from an SGD that is
compatible with cellular phone technology so that AAC user can become independent in making
calls for transportation, work, emergencies, and family/peer relationships.
Recipient and primary communication partner’s wishes and needs about communication (i.e.,
What do the AAC user’s parents, spouse, primary caregivers desire for this client?)
Output peripherals (i.e., AAC user needs a system that has voice output as well as text-tospeech output for more normalized interaction which is understood by all communication
partners in all environments. It would also be helpful if the SGD had an earphone option for the
auditory prompting that this student needs (This only applies to individuals who will be using
switch scanning with auditory prompts turned on).
7. Access
Describe optimal access technique(s) and describe method by which optimal access technique
was selected.
AAC USER has difficulty with fine and gross motor skills. He is ambulatory and walks
independently. AAC USER has limitations in his hands and has difficulty writing and hitting
keys on a typewriter/computer. AAC USER uses approximations of American Sign Language to
communicate about 150-200 words. Because of his fine motor delays, many of his signs are
altered and require the listener to be familiar with AAC USER. AAC USER demonstrated the
ability to isolate his index finger and directly select symbols on a speech generating device
(SGD). He did not appear to need the use of a keyguard in order to make accurate choices from a
field of 4, 8, 15, 32, and 45 icons.
8. Specifications for the SGD that Effectively and Efficiently Meets Recipient’s
Communication Needs (Discuss AT LEAST five features (more if needed) that are specifically
required to best meet the client’s communication needs.)
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The following SGD specifications are recommended to best meet AAC user’s communication
needs:
1) Vocabulary representation method (i.e., AAC user needs a system that is learnable with
structured teaching and is capable of providing a good variety of language representation
methods (i.e., single-meaning pictures, spelling, semantic compaction/Minspeak (i.e., the Unity
program) so that speed of messages can be maximized and both core and fringe/extended
vocabulary can be easily accessed. (If purchasing an ECO, you might also add “visual scene
technology” as a language representation method).
2) Symbol system (i.e., AAC user would benefit from using a combination of both the Unity
symbols as well as the available PCS (Picture Communication Symbols) from Mayer-Johnson as
he/she has been using low tech communication with the PCS symbols for some time now and has
established a degree of familiarity with the PCS symbols.)
3) Output modes (i.e., AAC user needs a device that can provide both verbal and written output.)
4) Intelligibility of output modes (i.e., AAC user needs an SGD with a wide variety of voice
options to most closely match different age levels as he/she continues to mature (i.e., child
voices, adolescent voices, adult voices).
4) Correctability of message (i.e., AAC user needs to have an SGD that allows for “clearing” and
“deleting” entire sentences, individuals words or single letters as needed.)
5) Device construction and durability (i.e., SGD should have a display that is easy to see under a
variety of lighting conditions (i.e., daylight, night time, etc.) SGD needs to be durable and able to
tolerate normal wear and tear. It needs to have sufficient battery capacity to run for a full day
without charging or changing batteries.)
6) Portability (i.e., AAC device user needs a device that can be easily transported in a carrying
case into all environments or AAC device user needs a device that can be easily mounted to
his/her wheel chair/bed and accessed in all environments that communication takes place or
AAC device user needs a device with a bright, large screen due to his/her visual impairments,
etc.)
7) Access/selection method (i.e., AAC user needs an SGD that has keys that are an appropriate
size for his/her present fine motor skills and can be fitted with a keyguard grid to increase fine
motor accuracy or AAC user needs an SGD that can be accessed with a switch, two switches, a
joystick or an infrared heap and allows for auditory prompting by label/key content so that
decreased visual skills will not impact his/her vocabulary selection.)
8)Future expansion capabilities (i.e., AAC user needs a device that can continue to grow in
vocabulary size and sophistication as he/she continues to increase his/her sentence length,
grammatical skills, and syntax.)
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9) Word predictability (i.e., AAC user needs a device with spelling as well as word prediction
capabilities so that he/she can better access fringe vocabulary that may not be preprogrammed.
Word prediction will increase accuracy of AAC user’s spelling as well as reducing the number of
keystrokes required to spell out a word.)
9. Description of the SGDs Under Consideration (minimum of three)
Comparison of SGD specifications:
The following speech generating devices were considered:
1. 7 -Level Black Communication Builder: This device manufactured by Enabling Devices,
is a digitized communication device that allows the user to speak 1, 2, 4, 8, or 16
different messages per level. Seven levels for recordings are available and permit a total
of 280 seconds of speech. The device has five removable frames, which are chosen
based on the user’s skill level. It is accessed through direct selection and has an
adjustable volume and built in handle. It is easily programmed and speech is recorded at
the push of a button. This is a static overlay device and the pre-made overlays have to be
manually changed. This device is portable and lightweight at 1.75 pounds.
2. Vantage: This device by the PRC offers a main vocabulary page of 4/8/15/45 and 84
locations. This portable device has a dynamic display with digital and synthesized speech
capabilities and a keyboard for written expression. The Minspeak language program uses
combinations of pictures to produce frequently used words within the chosen category.
The Vantage also has selective prediction to assist the user to recall the proper icon
combination to produce the desired word/sentence. Activation of a desired word usually
requires no more than 2-3 selections.
3. DynaVox MT4: This dynamic display device, by DynaVox Systems, Inc. is portable and
weighs 3.5 pounds. The MT4, a speech output device, offers synthesized speech and a
keyboard for written expression. The organization of the MT4 consists of a
category/main page with links to pages of vocabulary and concepts organized by
categories. The MT4 has the capability of displaying one to 50 symbols per page. This
device requires multiple hits to transition between pages.
Documentation why non-requested SGD does not meet recipient’s basic communication needs:
AAC USER demonstrates significant motivation when he is communicating with a Vantage
SGD. The quality and effectiveness of AAC USER’s interactions improves when he/she uses this
device. He/she participated in early literacy activities, requested toys/activities, and provided
personal information upon request. Using the Vantage, he/she initiated the use of the device and
was able to locate core vocabulary after minimal prompting. AAC USER required minimal
prompting to sequence multi-word phrases and enter the activity row and pages for
extended/fringe words. AAC USER was able to access symbols on 45-location template with
symbols ¾ inch in size.
AAC USER was able to utilize the 7-level Communication Builder. However, he/she is limited
to a finite number of locations on the board and is dependent on a caregiver to change the
overlays. This makes spontaneous and novel communication difficult for AAC USER. He/she
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needs to be able to transition between pages independently and have access to a wider variety of
vocabulary.
The Dynamyte seemed to be too complicated for AAC USER. He needed maximum cuing to
recall page-based sequences (to find toys and animals). Locating frequently used (CORE)
vocabulary was more difficult and time consuming for him/her with this device. AAC USER
was very distracted with the larger number of locations and navigating multiple pages to find a
single word.
10. SGD Prescribed
• Confirm if this is purchase or rental
• Plan for transition to purchase (if applicable)
• Benefits to recipient over other possible SGD
• Statement explaining why this SGD is the appropriate alternative that will meet the
recipient’s physical, cognitive, and language abilities and basic communication needs
• Ability to meet projected basic communication needs
• State how this system will provide the necessary rehabilitative, prosthetic and
preventative goals of communication
• Manufacturer/vendor (PRC, 1022 Heyl Road, Wooster, Ohio 44691 Phone: (800) 2621984)
11. Treatment Plan/Follow-up
Short and long-term communication goals:
It is recommended that AAC USER continue to receive individual speech therapy twice a week
for device training. AAC USER’s prognosis for using an augmentative communication device
independently is good.
Prognosis and duration of therapy are dependent on many factors including attendance,
motivation, learning capacity, physiological status, and home follow-through of therapy
assignments. The estimated duration of therapy is:
Long term goals:
1. To train family/teachers/facilitators to operate this device and program vocabulary, as
needed.
2. To train AAC USER in strategies of communicating effectively with his device to initiate
interactions as well as perform a variety of communication functions such as denial,
clarification, questioning, and commenting, etc.
Short term goals:
1. Client will accurately utilize CORE vocabulary words including common pronouns,
verbs, prepositions, adjectives, conjunctions, and determiners to build and create one
to three word spontaneous phrases.
2. Client will accurately make noun choices from the activity row and pages area.
3. Client will accurately use navigational tools such as “power on/off,” “clear,” “go
back,” and “delete character.”
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Persons responsible for training: (Usually the evaluating SLP.)
Projected changes in SGD: (Usually not applicable.)
Initial training and basic use of SGD: (May want to list local SERRC training dates or
online training dates that will be available via PRC.)
Implementation and integration into environments: Treatments will focus on using the
SGD in a wide variety of environments (i.e., home, school, community).
Necessary construction of modification of SGD to suit the recipient: (Usually not
applicable.)
12. Speech/Language Pathologist Information
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Name of evaluator
Address
Telephone number
License number
Pertinent information of the OT and/or PT
I declare that I am not an employee or have a financial relationship with the supplier of the
SGD.
Minspeak®, Semantic Compaction®, and Unity® are registered trademarks of Semantic Compaction® Systems, Inc. in the United
States and other countries. Minspeak® systems use the methodology derived from concepts covered by patents and patents
pending in the United States and in other countries. All Unity®, Minspeak®, and Semantic Compaction® brand systems and their
derivative works are copyrighted by Semantic Compaction® Systems, Inc., USA, 1984-2010.
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