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 ![[----------------Horizontal Rule----------------]](/webart/hrule.gif){kind=small}  2. Whose Outcome Is It Anyway?Let’s cast some illumination on the murky subject of outcomes in AAC. We shall begin by asking, "What is an outcome?" Taking an example from the sports world, quarterback Steve Young felt exhilarated after winning the Super Bowl. This exhilaration was the result of all the hard work Steve and his teammates put in during the season. Winning the Super Bowl was a very positive outcome for the San Francisco 49ers.Had they lost the contest, Steve would have felt very depressed, and the team would have experienced a very negative outcome to the season. The American Heritage Electronic Dictionary defines the word "outcome" as "a natural result; a consequence." In the rehabilitation and medical fields outcomes can be defined as "changes in status attributed to a specific intervention or treatment." Outcomes, then, are results caused by an event or series of events, or an action or series of actions occurring over time. Outcomes can be positive or negative. There usually is an expected outcome for any intervention or course of action. Measuring Outcomes Outcomes can be measured and studied. The science of outcomes measurement is defined as systematically measuring and analyzing treatment outcomes and using the findings to change the way care is provided. A person’s communications could be measured over time to see if the new communication device he has is improving his functional ability to communicate. Is he talking more effectively with more people with the device than without? Does it matter? Why should anyone care about all this mumbo jumbo? Is all this really that important? Yes, it is, and it’s going to be even more important in the years to come. As the dollars for goods and services gets scarce, outcomes will play an ever larger role in the AAC field. Forces within the AAC community, such as consumers, taxpayers, program administrators and funding agencies, want to make sure that goods and services are of value to both the client and to society. In short, people working in the field of AAC should get used to thinking in terms of delivering positive, measurable outcomes as well as goods and services.1 Forces in AAC In preparing to write this issue of Alternatively Speaking, I made a table of the various forces that could influence an outcome in AAC. It is rather amazing. The table has thirteen categories in it, and most of the categories include many different points of view, many different stakeholders. There certainly are a lot of forces pulling on AAC outcomes. The table (PLEASE NOTE: TABLES ARE NOT INCLUDED) "Forces in AAC" illustrates the forces, stakes and who is involved. In fact, not everyone is working toward the same outcomes. There is no unified team pulling towards the same goal. Indeed, as one looks at the chart of forces in AAC, one can envision many of these forces pulling from opposite ends of the rope. With people puling from different directions, who has the greater say in the area of outcomes? Certainly the persons who control the money (insurance companies, government funding agencies, tax payers and the like) appear to have more influence in the outcomes area simply because they often are paying the bills. A good model Consideration of outcomes is great, but how does one think about outcomes, and how does one measure them? The World Health Organization has a theoretical model that can help us think about outcomes. It is called the International Classification of Impairments, Disabilities and Handicaps. As the name implies, this model looks at disability from a three-level continuum.2 The first level is called "impairment." This focuses on an abnormality of psychological, physiological or anatomical structure or function at the organ level of the individual. For example, a person who has undergone head trauma may have a brain injury. The second level, "disability," focuses on the limitations caused by the "impairment." Looking at our fellow with the traumatic brain injury, that injury could affect his ability to communicate and solve problems. This level, called "disability," describes a person’s limitations, which can be measured before and after acquiring any adaptive techniques or tools, such as a communication device. The third level, "handicap," focuses on the societal disadvantages imposed on an individual as a result of "impairment or "disability." Our friend with the traumatic brain injury may experience problems in making and keeping new friends, finding employment and getting around in the everyday world. Specific interventions for this individual by professionals mainly will be aimed at the levels of impairment and disability. These are the areas in which professionals usually work, and these are the areas that produce the most quantifiable results. Our friend can receive traditional speech therapies on the impairment level that can be measured by improvements in articulation, intelligibility and rate of communication. An intervention on the level of disability would include the introduction of AAC devices, techniques and strategies. Improvement could be documented by functional and performance measures such as the number of interactions our friend has with other people. An intervention at the third, or handicap level, requires working with the individual and the community where he lives, works and plays. Clearly, this is the most difficult level on which to define measurable outcomes, because one is dealing with murky quality of life issues that are very subjective. Most professionals I’ve spoken with of late would rather work on the first two levels because they produce many numbers that can go in reports. Working on that third level is much harder because one is working with so many variables that can’t be controlled, and the resulting pay-offs are often a long time in coming and are not easy to quantify.3 Pulling together This report ends with a question: Whose outcome is it anyway? Is it the outcome of the people that control the money, the persons who want the quickest intervention at the lowest price? Is it the outcome of the program administrator who is always looking to put up good numbers in order to make his program look effective? Or might it be the outcome of the potential user of AAC? Will he receive and be trained in an AAC system he can use effectively so he can go forth and do battle on that all important third level? Isn’t this the outcome we all could be working towards? This article appears in AS Volume 2, # 1. You may order this issue by clicking on Ordering Home Page Online Ordering 
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