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Article 1: Effects of the Recession —
Assistive technology centers specializing in AAC.

Centers specializing in the area of augmentative and alternative communication (AAC) have played a critical role in the delivery of assistive technology and related services since the 1970s. Whereas Centers are no longer perceived as places where all AAC services can or should occur, they are uniquely prepared to deliver high quality, sophisticated services because they:

At a time when the laws and public policies of many nations have extended the rights of persons with disabilities and have mandated access to assistive technology and related services, one would expect to see new assistive technology centers emerging. This is not the case. Instead, governments, educational agencies, health-care institutions and other funding sources are struggling with cutbacks and facing deficits. Institutions are hiring administrators who know about business and financial planning, but who often have no understanding or appreciation of rehabilitation, never mind AAC. Looking at staff productivity, i.e., number of direct patient contact hours, they may view AAC services as a liability. Even facilities that continue to place a value on innovation and respect expertise are treading water. Unfortunately, well-equipped centers quickly become outdated facilities if little time and money is set aside for learning and equipment. As a result, some institutions are no longer perceived as valuing the people they serve, specialty programs, or professionals with expertise. Rather they seem only to value the bottom line: money.

The following case examples are offered as samples of how five well-established programs and centers of excellence are coping with today's fiscal realities in North America. Although all are located in hospitals, don't stop reading if you work in a school, nursing home, etc. or live somewhere else. You face similar issues.

Case #1 – Rehabilitation Technology Program (RTP)

Several months ago, Pamela Andersen suggested ACN tackle this topic. She had a story to tell and felt it might be helpful to others. As Director of the Rehabilitation Technology Program (RTP) at Penrose Hospital, a non-profit, Catholic hospital in Colorado, Pam received the RTP’s status reports from the hospital. For six years billings for RTP services had shown a $50-60,000 yearly profit (on paper). Program statistics revealed 30% of staff time was spent on evaluations, 60% on treatment, and 10% on consultation. Their community-based treatment model was carried out in schools, nursing homes, group homes, etc. Staff regularly attended conferences, did some research and remained active in the AAC community.

The bubble burst 18 months ago when the hospital calculated monies actually collected from payers for RTP services. They faced a $10,000 deficit, due in large part to the percentage of patients funded by Medicaid. The hospital was being reimbursed only 44% (i.e., 55% of 80%) of what it had billed. Anderson said "We were benefiting people, but not the hospital. We needed to adjust what we were doing and how we were doing it to stay in business."

The past 18 months have been "difficult," but, today, the RTP is breaking even and headed toward profitability. Changes made include:

1. Shifting how staff perceive the mission. The mission is to "empower" rather than "take care of" clients, families, and community professionals. Responsibility for treatment is being shifted to community professionals and families, and signed commitments are asked for upfront.

2. Shifting expectations. Staff are more realistic. They lay out treatment plans in small steps. They recommend sophisticated equipment only if adequate support is in place. Also, when no progress is made or minimal interest is shown, staff are learning to "let it go," i.e, focus energies elsewhere.

3. Reassigning staff. Eighteen months ago the RTP had 7 FTE (full time equivalent) staff; today there are 3 FTEs. Staff previously dedicated to the RTP are now working in other parts of the hospital (trauma recovery, neurological disorders) as consultants. This also spreads the expertise around and sets up an expectation for cross training.

4. Finding reliable funding. More and better funding sources are being identified (i.e., vocational rehabilitation, auto insurance, private insurance). Cost benefit analyses are being made available to payers.

5. Seeking a patient mix. The program actively seeks a mix of patients and funding sources. For example, they see individuals with spinal cord injury, cerebral palsy, carpal tunnel syndrome, and so on.

Andersen feels the changes have not compromised the quality of care. In fact, the emphasis on empowering consumers and the community seems to have improved outcomes for everyone at the RTP.

Case #2 - Assistive Device Service (ADS)

Due north, Elaine Heaton, of the Assistive Device Service (ADS) at Glenrose Rehabilitation Hospital in Edmonton, Canada, reports a team of 5 FTEs provides services to children and adults in the areas of communication, mobility, computer access, and environmental control. Under the socialized Canadian health care system, the provincial government pays for clinical services. In Alberta, however, outside funding must be sought for AAC devices, switches, and mounting systems. Elaine feels multidisciplinary programs, like the ADS, currently have a perceived high value at Glenrose. However, internal review committees are beginning to look at costs more carefully and staff cutbacks already have occurred. "Assistive technology services are at risk," says Heaton. For example, 2.8 FTEs were lost in the speech department and 1.0 FTE in the ADS. Staff are working hard to operate as efficiently as possible. They maintain a high profile and good public relations. Heaton feels a strong consumer movement and the involvement of physicians also are needed.

Case #3 –Augmentative Communication Services

In Toronto, Ontario, the Hugh MacMillan Medical Centre's Augmentative Communication Services (ACS) was established in 1979. It has clinical, educational, and research components. Penny Parnes, Director of ACS and Vice President of Professional Services at the Centre, says "we have always worked closely with our funding source, i.e., the provincial government." Although the Canadian delivery system is not "fee for services," and no money is exchanged, the Hugh MacMillan Medical Centre is "not oblivious to the costs." Neither is the government. ACS and other centers have been authorized by the provincial government to recommend equipment and provide comprehensive services. A recently funded project at ACS (the Central Equipment Project) is assisting programs to pool equipment. Although the assistive technology device program was due to expand to adults two years ago, funding considerations are delaying this.

Penny said ACS's years of experience has taught them important lessons:

Reflecting this information and in order to be efficient and effective, ACS revised its delivery model two years ago. The efficacy of the model described below is being evaluated.

1.Today, when an inquiry is made, the initial intake requires the involvement of a community-based team.

2. The family and community-based professionals must apply to ACS each year for specific services the following year. Applications specify the composition of the community team and strengths available within the community.

3. ACS staff meets to determine how best to serve the needs of those requesting services during the year. The level of services can vary from none, to minimal consultation, to intense ongoing intervention and training.

4. Once a level of services is agreed upon, ACS staff collaborates with the community team to set goals and plan the intervention program for the year.

5. The program is implemented throughout the year in the community. ACS staff work to empower community teams.

6. The community team evaluates the effectiveness of ACS services.

Case #4 – Communication Enhancement Center/Institute on Applied Technology

Back in the U.S.A., we focus on another well-established program, the Communication Enhancement Center at Children's Hospital in Boston, MA. Founded in 1977 and expanding in 1988 to include the Institute on Applied Technology, the Center employs 15 people (speech-language pathologist, reading specialist, engineer, special educator, occupational therapist, secretary, administrator, and a director). Howard Shane, Director, says the "hospital supports the program, but we are expected to break even."

In 1985, the Center faced a growing deficit. Clinical services were so labor intensive that Shane concluded funds had to be generated from outside of the clinical services program in order for it to survive. He identified several options:

1.Be part of an institution that absorbs the loss

2. Be a vendor and sell manufacturer's equipment

3. Find a benefactor to provide a very large donation

4. Develop and sell equipment

5.Pursue grants from governmental agencies, from individuals and other organizations/companies to fund specific projects.

6. Redefine the types of services being provided.

The first option is not an option. Option #2 was tried, but dispensing AAC equipment was not a satisfactory experience. Howard, like everyone else, is still waiting for a large benefactor to make Option #3 come true. Option#4 was undertaken with success. The Institute is developing products in collaboration with Digital Equipment Corporation to adapt or develop products that can benefit individuals with disabilities. Today they provide equipment they were involved in developing. Option #5 is ongoing and actively pursued. An example is their Mobile Van funded and maintained by a local organization. They have expanded clinical services to provide a range of assistive technology services to both adults and children (Option #6).

Case #5 – Center for Applied Rehabilitation Technology (CART)

The Center for Applied Rehabilitation Technology (CART) at Rancho Los Amigos Medical Center in Los Angeles was established as the result of a generous donation of nearly 2 million dollars (Note: that's option #2). CART has over $450,000 worth of assistive technology. Frank DeRuyter, Director of CART, says the service delivery component includes: Resource, Information/Referral and Assessment. Personnel costs for Resource and Information/Referral components are not easily recaptured, but can be handled by volunteers, clerical and supportive personnel. However, personnel costs for the assessment component are high because services are provided by professionals with advanced degrees, licenses, and a high level of expertise who participate in continuing education to stay up-to-date.

Frank can prove the delivery of assistive technology is a "money loser . . . under current provisions for funding services." He cites personnel costs, decreased productivity statistics and the cost and limited shelf life of equipment. For example, productivity requirements in hospitals and rehabilitation centers expect therapists to bill between 5 and 6 hours of direct patient contact per day. The data show the productivity for those in CART are 18-23 percent lower than their colleagues in other areas of rehabilitation because billable time is lower. It is not because they are less productive! DeRuyter, Doyle, and Kennedy's (1990) survey results show productivity for speech-language pathologists in brain injury programs average 5.2 hours/ day for speaking patients and 4.3 hours/day for nonspeaking patients. AAC services are very labor intensive and costs are difficult to retrieve. Frank says it is not unusual for only 55 percent of charges for a comprehensive AAC evaluation taking an average of 6 staff hours to be reimbursed at CART. A minimum of 5 hours of a speech-language pathologist's time typically is required to conduct an AAC evaluation, select a system and provide minimal training. For this, the hospital may collects as little as $88.96 from some payer sources.

DeRuyter concludes that if services for assistive technology are going to increase, funding mechanisms must be reexamined.

Assistive technology centers that are consumer oriented and facilitate collaboration with community- based professionals and manufacturers, are critical components of service delivery in the area of AAC. Without the leadership and continuity they provide, the field of AAC will suffer. Those interviewed concur. There is plenty of business, i.e., people need assistive technology. Although the current recession makes it a scary time to jump in, all agree it can be done. Suggestions below summarize considerations applying to programs across settings.

1. Study the market and develop collaborative partnerships. Determine who needs/wants what services. Sit down with your "customers" and devise consumer responsive models that foster independence, not dependence in your geographic area.

2. Involve decision-makers. If you are located in a hospital, you need the support of an influential physician. In school districts and government agencies, administrative support is critical. Those who don't have it will have trouble down the road. Table I (not included) lists 6 strategies for gaining administrative support.

3. Decide what you can do with what you've got, and then do it with excellence. Call yourself what you are. Make sure you have the resources to do the job very, very well!

4. Study, work with and educate payer sources. Look carefully at who is being provided with services and equipment and what potential sources of funding exist. Meet with funding agencies so they understand what AAC is and why and how a communication device can allow a person to live and work.

5. Be certain staff are committed. Then, consider carefully how best to use their expertise. Be creative in how you cut costs.

6. Specify what your overhead needs are.

7. Be visible. Develop a plan to promote the program. Remember Centers need outside sources of funding and support (e.g., governments, benefactors, grants/contracts). Be sure to allocate time, energy, and expertise to pursuing these options.

8.Be efficient. Save time and energy by keeping information/materials on a data-base and by providing education in groups/workshops. Also to increase efficiency, use available products such as Hyper AbleData and Board Maker (see References ). Don't re-invent solutions . . . maintain contact with colleagues with expertise!

9.Be realistic. Define expectations upfront. Proceed slowly. Recommend equipment that can easily be supported in the community. Make sure you know the effects of your services, and how others perceive your services.

10. Plan growth carefully. Consider the financial impact of all decisions. Make decisions based on data, i.e., statistics, outcome studies. Do not make decisions that compromise quality of care.

What's in the Future?

• Encouraging consumer societies and organizations (Amyotrophic Lateral Sclerosis Society, Spastic Society, Hear Our Voices) to consider taking on more responsibility for disseminating information, making referrals, and recycling equipment?

This article appears in ACN Volume 4, # 6.

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