A qualitative study of adult AAC users’ experiences communicating with medical providers

A qualitative pilot study of adult AAC users' experiences related to accessing and receiving mental health services

There is currently limited research related to mental health supports for individuals who use AAC, particularly about the actual lived experiences of AAC users who receive mental health services. There may be alterations to mental health services for individuals who use AAC. The aim of this study was to gain the perspectives of AAC users on accessing and receiving mental health services. Three participants who used AAC and received mental health services shared their experiences related to receiving mental health services. Data were analyzed using an inductive approach in which themes were based on participants' experiences. Five major themes were generated: (a) Time, (b) Communication Partner Skills, (c) Advocacy, (d) Means of Expression, and (e) Diagnosis. Participants described factors that positively or negatively impacted their experiences. Participant experiences were examined in light of Bronfenbrenner's Ecological Systems model. The findings of this study provide insights into the perspectives of individuals who use AAC in accessing mental health services, uncovering various barriers and facilitators within the patient-psychotherapist microsystem. Factors such as time constraints, communication partner skills, advocacy, means of expression, and diagnosis-related challenges significantly influenced the quality of interaction between patients using AAC and their mental health provider. The study also reveals the broader impacts of AAC on interactions within the meso-, exo-, and macro-systems, suggesting the need for improved involvement of speech-language pathologists and policy changes to support effective communication and accessibility for individuals using AAC in mental health settings. Ultimately, future research should involve participants of varying ages, diagnoses, and backgrounds and should include a variety of stakeholders.

How Health Care Organizations Are Implementing Disability Accommodations for Effective Communication: A Qualitative Study

BACKGROUND

Prior studies have documented that, despite federal mandates, clinicians infrequently provide accommodations that enable equitable health care engagement for patients with communication disabilities. To date, there has been a paucity of empirical research describing the organizational approach to implementing these accommodations. The authors asked US health care organizations how they were delivering these accommodations in the context of clinical care, what communication accommodations they provided, and what disability populations they addressed.

METHODS

In this study, 19 qualitative interviews were conducted with disability coordinators representing 15 US health care organizations actively implementing communication accommodations. A conventional qualitative content analysis approach was used to code the data and derive themes.

RESULTS

The authors identified three major themes related to how US health care organizations are implementing the provision of this service: (1) Operationalizing the delivery of communication accommodations in health care required executive leadership support and preparatory work at clinic and organization levels; (2) The primary focus of communication accommodations was sign language interpreter services for Deaf patients and, secondarily, other hearing- and visual-related accommodations; and (3) Providing communication accommodations for patients with speech and language and cognitive disabilities was less frequent, but when done involved more than providing a single aid or service.

CONCLUSION

These findings suggest that, in addition to individual clinician efforts, there are organization-level factors that affect consistent provision of communication accommodations across the full range of communication disabilities. Future research should investigate these factors and test targeted implementation strategies to promote equitable access to health care for all patients with communication disabilities.

Older adults with communication disabilities and their use of communication support at doctor's visits: a nationally representative study

PURPOSE

Older adults with communication disabilities (CDs) experience barriers to receiving care and face a paucity of accommodations for their disability. Utilizing someone that supports communication with healthcare providers (communication support persons) may be a way that this group self-supports their disability. We examined if this utilization was independently associated with CDs among older adults. We also sought to understand if socioeconomic factors were associated with utilization.

METHODS

We used the 2015 National Health and Aging Trends Survey (NHATS) to conduct a cross-sectional analysis of Medicare beneficiaries (n = 5954) with functional hearing, expressive, or cognitive difficulties. We calculated a weighted, population prevalence and an adjusted prevalence ratio (APR) controlling for sociodemographic, health and other disability factors.

RESULTS

Among community dwelling older adults, having CDs was associated with higher utilization of a communication support person at medical visits (APR: 1.41 [CI: 1.27 - 1.57]). Among adults with CDs, Black adults and women had lower levels of utilization as compared to White adults and men, respectively.

CONCLUSION

Communication support persons may be a way that older adults with CDs self-support their disability. However, not all older adults with CDs bring someone and variation by social factors could suggest that unmet support needs exist.

Preferred Communication Strategies for People with Communication Disabilities in Health Care Encounters: a Qualitative Study

BACKGROUND

People with communication disabilities (CDs), which includes disabilities in speech, language, voice and/or hearing, experience health and healthcare disparities. A barrier to accessing high-quality, equitable care is the lack of effective communication between patients and their providers.

OBJECTIVE

In designing a patient-prompted tool to facilitate communication, we analyzed qualitative feedback on communication strategies and the experience of people with CDs, caregivers, and providers in healthcare encounters. We aimed to describe communication strategies that patients with CDs find most useful and optimize a tool for patients to share their communication strategy preferences during clinical encounters. While patient-provider communication is paramount in every interaction, we aimed to highlight the intricacies of optimizing communication for this population.

DESIGN

We performed a qualitative study utilizing focus groups and interviews with patients with CDs, their caregivers, and healthcare providers.

PARTICIPANTS

A total of 46 individuals participated in focus groups or interviews; 26 participants self-reported a CD, nine were caregivers, and 11 were providers. Participants represented diverse types of CDs, including stuttering, aphasia, hearing loss, and people with autism or cerebral palsy who use assistive technology to communicate.

APPROACH

Analysis of qualitative interview and focus group data was guided by a qualitative content analysis approach.

KEY RESULTS

We identified three themes: (1) While communication strategies should be individualized, participants agreed upon a consolidated list of best strategies and accommodations. We used this consolidated list to finalize tool development. (2) Patients and providers preferred disclosure of the CD and desired communication strategies before the appointment. (3) Providers often do not use communication strategies and accommodations during clinical encounters.

CONCLUSIONS

For patients with CDs, it is critical to acknowledge and document the CD and individualize communication strategies during healthcare visits to facilitate communication. Studies are needed to evaluate whether improved communication strategy usage leads to improved health outcomes for this population.

Altered tongue muscle contractile properties coincide with altered swallow function in the adult Ts65Dn mouse model of down syndrome

Purpose

Down syndrome (DS) is a developmental disability associated with difficulties in deglutition. The adult Ts65Dn mouse model of DS has been previously shown to have differences in measures of swallowing compared with euploid controls. However, the putative mechanisms of these differences in swallowing function are unclear. This study tested the hypothesis that the Ts65Dn genotype is associated with atypical measures of tongue muscle contractile properties, coinciding with atypical swallow function.

Methods

Adult (5-month-old) Ts65Dn (n = 15 female, 14 male) and euploid sibling controls (n = 16 female, 14 male) were evaluated through videofluoroscopy swallow studies (VFSS) to quantify measures of swallowing performance including swallow rate and inter-swallow interval (ISI). After VFSS, retrusive tongue muscle contractile properties, including measures of muscle fatigue, were determined using bilateral hypoglossal nerve stimulation.

Results

The Ts65Dn group had significantly slower swallow rates, significantly greater ISI times, significantly slower rates of tongue force development, and significantly greater levels of tongue muscle fatigue, with lower retrusive tongue forces than controls in fatigue conditions.

Conclusion

Tongue muscle contractile properties are altered in adult Ts65Dn and coincide with altered swallow function.

Asynchronous online focus groups for research with people living with amyotrophic lateral sclerosis and family caregivers: usefulness, acceptability and lessons learned

BACKGROUND

People with amyotrophic lateral sclerosis (ALS) face disability- and travel-related barriers to research participation. We investigate the usefulness and acceptability of asynchronous, online focus groups (AOFGs) for research involving people affected by ALS (patients and family caregivers) and outline lessons learned.

METHODS

The ALS Talk Project, consisting of seven AOFGs and 100 participants affected by ALS, provided context for this investigation. Hosted on the secure itracks Board™ platform, participants interacted in a threaded web forum structure. Moderators posted weekly discussion questions and facilitated discussion. Data pertaining to methodology, participant interaction and experience, and moderator technique were analyzed using itracks and NVivo 12 analytics (quantitative) and conventional content analysis and the constant-comparative approach (qualitative).

RESULTS

There was active engagement within groups, with post lengths averaging 111.48 words and a complex network of branching interactions between participants. One third of participant responses included individual reflections without further interaction. Participants affirmed their co-group members, offered practical advice, and discussed shared and differing perspectives. Moderators responded to all posts, indicating presence and probing answers. AOFGs facilitated qualitative and quantitative data-gathering and flexible response to unanticipated events. Although total participation fell below 50% after 10-12 weeks, participants valued interacting with peers in an inclusive, confidential forum. Participants used a variety of personal devices, browsers, and operating systems when interacting on the online platform.

CONCLUSIONS

This methodological examination of AOFGs for patient-centred investigations involving people affected by ALS demonstrates their usefulness and acceptability, and advances knowledge of online research methodologies. Lessons learned include: early identification of research goals and participant needs is critical to selecting an AOFG platform; although duration longer than 10-12 weeks may be burdensome in this population, participants were positive about AOFGs; AOFGs offer real world flexibility enabling response to research challenges and opportunities; and, AOGFs can effectively foster safe spaces for sharing personal perspectives and discussing sensitive topics. With moderators playing an important role in fostering engagement, AOFGs facilitated rich data gathering and promoted reciprocity by fostering the exchange of ideas and interaction between peers. Findings may have implications for research involving other neurologically impaired and/or medically vulnerable populations.

Recognising Basic Health Literacy Capabilities: An Explorative Study on the Relevance of Health-Related Information in the Support of People with Profound Intellectual and Multiple Disabilities

Background: People with profound intellectual disabilities represent a vulnerable and heterogeneous population whose health-related needs and questions often remain unheard. One reason for this is that they are usually unable to participate in verbal communication. However, there is also a lack of suitable approaches to communicate health-related information to them according to their capabilities. The research presented in this paper addresses this gap. Methods: Following grounded theory methodology, we used a multimethod approach. Based on a theoretical analysis, a Delphi study (n = 14) was conducted as a starting point to map the research field. In a second step, these findings were incorporated into an online survey targeting disability care professionals (n = 111). Three field studies supplemented the data, encompassing a variety of ethnographic methods. Results: People with PIMD have basic health-related capabilities that can improve their health literacy. Nevertheless, their support environments have to take over many health literacy-related requirements by proxy or substitution. One of the most important tasks is to engage health information in an individualised way. Conclusions: The findings underline the importance of focusing on more basic capabilities and intersubjective approaches in health literacy research and practice, especially regarding new perspectives on the inclusion of previously marginalised populations (such as people with PIMD).

Striving Toward Equity in Health Care for People With Communication Disabilities

PURPOSE

Approximately 10% of the U.S. adult population has a speech, language, and/or voice disability, collectively referred to as communication disabilities. An increasing number of studies demonstrate that persons with communication disabilities have worse health and health care outcomes as compared to those without communication disabilities. Understanding the state of the science, including potential contributing factors is critical to begin to address the disparities.

METHOD

Applying a historical lens and integrating multiple models of disability provide a comprehensive perspective of the health and health care outcomes of persons with communication disabilities.

RESULTS

Three phases for addressing health care disparities exist: detecting, understanding, and reducing. Results from a 2012 National Health Interview Survey provide compelling population-level results of the health and health care disparities experienced by persons with communication disabilities. To understand the disparities, factors within the health care system, such as availability of communication aids and services, as well as provider and staff biases, assumptions, and lack of knowledge need to be considered. To date, few interventions exist to address disparities in care for persons with communication disabilities. Consequently, researchers need to engage with stakeholders in innovative study designs and methods to facilitate the rapid development, implementation, and dissemination of interventions that address the disparities.

CONCLUSION

To ensure equity for the large and growing population of persons with communication disabilities, researchers, policy makers, patients, and health care systems need to collaborate in identifying and addressing the factors contributing to health and health care disparities. Presentation Video: https://doi.org/10.23641/asha.21215804.

Supporting Access to Mental Health Services for Patients Who Use Augmentative and Alternative Communication: A Proposed Framework and Suggestions for Future Directions

PURPOSE

The purpose of this review article is to examine interacting factors that affect the psychotherapeutic process for patients who use augmentative and alternative communication (AAC). This is examined from two perspectives: (a) how the skills and needs brought by the individual with communication disabilities influence the process of therapy and (b) how the individual's ecological systems may affect an individual's mental health and their access to mental health supports. Understanding these factors will guide future efforts aimed at ensuring that individuals with communication disorders have adequate access to services and supports for mental health.

METHOD

A narrative synthesis approach was used to explore the interaction of psychotherapy and the use of AAC. Existing research in the fields of psychotherapy and speech-language pathology was examined for its relevance to issues of communication using AAC. Specifically, information was synthesized concerning mental health, prevalence rates of mental health diagnoses, the provision of traditional psychotherapy, and communicating via AAC in order to describe the intersection of psychotherapy and AAC. This narrative synthesis approach sought to initiate discussion of relevant factors that may affect the psychotherapeutic process for patients who use AAC.

RESULTS

A variety of factors may affect the psychotherapeutic process for patients who use AAC. Bronfenbrenner's (1977) Ecological Systems Theory was used to explore access to mental health services for individuals who use AAC at the levels of microsystem, mesosystem, exosystem, and macrosystem. Such factors include alterations to communication between patient and psychotherapist, skills brought by the patient, involvement of a communication assistant and/or speech-language pathologist, education and skill level of the psychotherapist, appropriateness of billing codes, and system and policy factors that may affect the provision of mental health services to patients who use AAC.

CONCLUSION

It is necessary to explore the factors that affect the provision of psychotherapy for patients who use AAC in order to more fully address the mental health needs of individuals with communication disorders. Further research is needed to determine the impacts of these factors and ways to address those impacts.

Understanding How Older Adults with Communication Difficulties Access Health Services: What We Can Learn from the National Health and Aging Trends Study (NHATS)

People with communication disorders face barriers to accessing safe and respectful healthcare. These barriers result in increased healthcare complications and inefficiencies, both of which contribute to increased healthcare costs. One obstacle to advocating for accommodations that could improve healthcare for this population is the absence of cost effectiveness studies of such accommodations specifically, as well as a paucity of data defining the needs of this population in general. The purpose of this study was to explore how people with communication and swallowing difficulties are characterized in the National Health and Aging Trends Study (NHATS), a nationally representative survey of Medicare beneficiaries aged 65 and older, and how they manage their healthcare. Cross-sectional data from the NHATS rounds 5 to 9 (2015-2019) resulted in 8,038 unique respondents, 3,243 of who reported speech, memory, hearing, and/or swallowing difficulties. More than 90% of respondents with communication difficulties reported having a regular doctor. Less than 60% of respondents with communication difficulties had a family member or caregiver go to medical appointments with them, and around 70% of that subset of participants received help from that caregiver with communication during appointments. Fewer than 15% of respondents with communication difficulties used the internet for healthcare communication or information. Less than 5% of respondents across all communication difficulty categories had received rehabilitation services for communication in the year prior to their survey responses. While the information gleaned from NHATS points to likely gaps between the needs people with communication disorders may have for safe and accessible healthcare, and the support available, future research is needed to improve and clarify how communication disorders are defined and characterized in large-scale surveys to generate more interpretable data. These stronger empirical foundations are needed to support cost-effectiveness analyses to advocate for better communication accessibility of healthcare settings.

Communication experiences of healthcare students whilst managing adults with communication disorders

Background

Research has found that people with communication disabilities are three times more likely to encounter medical mishaps. Almost a third of patients with speech-language therapy (SLT) diagnoses have other medical conditions across more than one of the burden of disease categories. Fifty per cent of these patients present with communication disorders. Student healthcare curriculums focus on patient dynamics and field-specific diversities. It does not often include the skills and knowledge required to effectively communicate and treat those with communication disorders.

Objectives

This study aims to describe the communication challenges and strategies employed by a group of final year Nursing, Medicine, Dietetics and Human Nutrition, Physiotherapy and Occupational Therapy students when managing adults with communication disorders.

Method

A qualitative, phenomenological study design was used. Questionnaires were electronically distributed, and results were analysed thematically.

Results

The most significant challenges whilst managing adults with communication disorders were patients’ receptive and expressive language difficulties. Further challenges included lack of knowledge surrounding communication disorders, lack of training in the use of appropriate communicative assistive devices, factors within the physical environment and gaps in students’ clinical performance. Strategies used to facilitate communication included caregiver assistance, gestures and written language.

Conclusion

This study revealed that there is a need to develop healthcare students’ skills in managing adults with communication disorders. This is because of the challenges faced and inefficiency of the strategies used. Future research should focus on determining solutions for improved communication with adults with communication disorders. The study highlights the need for further education and training to address students’ communication needs with patients.

Examining Face Validity of Visual Stimuli Used in Preference Assessments for Older Adults With Communication Impairments

PURPOSE

Preference assessment is integral to person-centered treatment planning for older adults with communication impairments. There is a need to validate photographs used in preference assessment for this population. Therefore, this study aimed to establish preliminary face validity of photographs selected to enhance comprehension of questions from the Preferences for Everyday Living Inventory-Nursing Home (PELI-NH) and describe themes in older adults' recommendations for revising photographic stimuli.

METHOD

This qualitative, cognitive interviewing study included 21 participants with an average age of 75 years and no known cognitive or communication deficits. Photographic stimuli were randomized and evaluated across one to two interview sessions. Participants were asked to describe what the preference stimuli represented to them. Responses were scored to assess face validity. Participants were then shown the PELI-NH written prompt and asked to evaluate how well the photograph(s) represented the preference. A semideductive thematic analysis was conducted on interview transcripts to summarize themes in participant feedback.

RESULTS

Forty-six (64%) stimuli achieved face validity criteria without revisions. Six (8%) stimuli achieved face validity after one partial revision. Twenty (28%) stimuli required multiple revisions and reached feedback saturation, requiring team review for finalization. Thematic analysis revealed challenges interpreting stimuli (e.g., multiple meanings) and participant preferences for improving photographs (e.g., aesthetics).

CONCLUSIONS

Cognitive interviewing was useful for improving face validity of stimuli pertaining to personal care topics. Abstract and subjective preferences (e.g., cultural traditions) may be more challenging to represent. This study provides a framework for further testing with older adults with cognitive, communication, and hearing impairments.

Health service use among adults with cerebral palsy: a mixed-methods systematic review

AIM

To determine the proportion of adults with cerebral palsy (CP) using health services and frequency of use, and to explore experiences and perceptions of health services for this population.

METHOD

A mixed-methods systematic review was conducted using the Joanna Briggs Institute methodology. Five databases were searched to September 2020. Observational and qualitative studies were included. Two reviewers screened titles, abstracts, and full texts; extracted data; and assessed the quality of included studies. Separate meta-analyses were used to pool the proportion of adults using each service and frequency of use. A meta-aggregation approach was used to synthesize qualitative data. Quantitative and qualitative findings were integrated using the Andersen and Newman Model of health care utilization.

RESULTS

Fifty-seven studies (31 quantitative, 26 qualitative) of 14 300 adults with CP were included. The proportion of adults using services ranged from 7% (95% confidence interval [CI]: 2-13%) for urologists to 84% (95% CI: 78-90%) for general practitioners. Incidence of visits ranged from 67 (95% CI: 37-123) hospital admissions to 404 (95% CI: 175-934) general practitioner visits per 100 person-years. Qualitative themes highlighted issues regarding accessibility, caregivers' involvement, health workers' expertise, unmet ageing needs, transition, and health system challenges.

INTERPRETATION

Adults with CP used a wide range of health services but faced context-specific challenges in accessing required care. Appropriate service delivery models for adults with CP are required. This review emphasizes a need to develop an appropriate service model for adults with CP to meet their needs.

Telehealth experiences of providers and patients who use augmentative and alternative communication

OBJECTIVE

We explore the telehealth experiences of adults who use augmentative and alternative communication (AAC) and clinicians who work with people using AAC.

MATERIALS AND METHODS

We conducted semistructured, online interviews with 6 adults who use AAC and 8 clinicians who provide telehealth services to people who use AAC between July and September 2020. Participants were located in the United States and the United Kingdom. All participants had engaged in 2 or more telehealth visits in the past 6 months. We used an inductive, thematic approach to analyze the interview data.

RESULTS

Our findings reveal that (1) telehealth is an essential service, (2) technology causes barriers, (3) policies meant to protect actually inhibit, and (4) remote monitoring devices have the potential to mitigate risks.

DISCUSSION

Telehealth systems created for persons without disabilities do not provide equitable access to everyone. Telehealth should be flexible enough to allow patients to use the communication modality that best meets their needs. We suggest that healthcare systems think of the healthcare ecosystem as one which includes a variety of telehealth options in addition to traditional in-person clinical visits.

CONCLUSIONS

The benefits of telehealth for people who use AAC are substantial and should be an option for ongoing health care. However, the accessibility of telehealth technologies needs to be improved. Designers should view telehealth as part of a broad healthcare ecosystem, which includes in-person, telehealth, and remote health monitoring technologies. Designers should also include AAC users in the design and development process. Telehealth policies should encourage multimodality access to health care and address funding concerns.

Perspectives of Patients with Diverse Disabilities Regarding Healthcare Accommodations to Promote Healthcare Equity: a Qualitative Study

BACKGROUND

Patients with disabilities often require healthcare accommodations in order to access high-quality, equitable healthcare services. While attention has been paid to accommodation needs in specific disability populations, limited research to date has explored healthcare accommodations that cross-cut diverse disability populations.

OBJECTIVE

To identify a deeper understanding regarding accommodations in healthcare settings that could apply across disability populations and promote equitable healthcare.

DESIGN

We conducted qualitative focus groups with patients with disabilities and caregivers to understand their experiences and preferences for healthcare accommodations.

PARTICIPANTS

We recruited patients and caregivers across all major disability categories to participate in focus groups. Participants were recruited through advocacy organizations and healthcare settings in Southeastern Minnesota.

APPROACH

A total of eight focus groups were conducted with 56 participants. Participants described their healthcare experiences and desires for healthcare accommodations. The multidisciplinary research team recorded, transcribed verbatim, and coded all focus groups. The team thematically coded transcripts using content analysis within and across focus groups to identify major themes.

KEY RESULTS

Patients identified four challenges and corresponding steps healthcare team could take to promote equitable care: (1) consistent documentation of disabilities and needed accommodations in the medical record; (2) allowance for accommodations to the environment, including adapting physical space, physical structures, and scheduling and rooming processes; (3) provide accommodations for administrative tasks, such as completing paper or electronic forms; and (4) adapt communication during interactions, such as speaking slower or using terms that patients can easily understand.

CONCLUSION

These identified themes represent specific opportunities for healthcare teams to effectively provide accessible care to patients with disabilities. Many of the accommodations require minimal financial investment, but did require behavioral changes by the healthcare team to ensure equitable healthcare.

Training students from rehabilitation professions on communicating with patients with communication disorders

BACKGROUND

FRAME, a mnemonic referring to a program for helping health care providers adapt patient-provider communication when working with patients with communication disorders, improves the knowledge, confidence, and communication skills of medical students for working with this population. However, the impact of the FRAME program for preparing students from the rehabilitation disciplines to work with patients with communication disorders is unknown.

OBJECTIVE

To examine the effects of the FRAME program on the knowledge, confidence, and communication skills of students in physical therapy (PT), occupational therapy (OT), and prosthetics and orthotics (P&O) in terms of how to communicate effectively with patients with communication disorders.

DESIGN

An exploratory, quasi-experimental pretest-posttest design.

SETTING

PT, OT, and P&O clinical education programs at the University of Washington's Department of Rehabilitation Medicine.

PARTICIPANTS

Twenty rehabilitation students (PT = 12; OT = 7; and P&O = 1) participated in the FRAME training.

INTERVENTIONS

The FRAME program, delivered in a single, 2-hour session teaches students communication skills to use with patients with various types of communication disorders.

MAIN OUTCOME MEASURES

A quiz of students' knowledge about communication disorders and a self-rating of confidence for interacting with this patient population were used. Speech-language pathology graduate clinicians rated students' use of communication strategies from each area of the FRAME training during interactions with standardized patients portraying aphasia and dysarthria. Student qualitative feedback were also collected.

RESULTS

Students' knowledge, confidence, and use of communication strategies improved significantly following training. Greatest gains were observed in students' ability to familiarize themselves with how a patient communicates and establish a method of communication before proceeding with the interview. Qualitative feedback aligned with these findings.

CONCLUSIONS

The FRAME program increases the knowledge, confidence, and use of communication strategies in rehabilitation students in order to communicate more effectively with patients with communication disorders in their future careers.

Training Medical Professionals to Work with Patients with Neurodevelopmental Disorders: A Systematic Review

Background: Patients with neurodevelopmental disorders are not always provided the quality of medical care they deserve. Medical personnel report limited preparation and education in caring for patients with neurodevelopmental disorders.  Aim: The purpose of this systematic review is to summarize the research on medical personnel training programs, identify effective training methods, and provide directions for future application and research. Methods: Thirty-four studies met inclusion criteria. The studies were summarized in terms of training components, the medical personnel trained, and the effectiveness of the training in achieving target outcomes.  Results: Seventy-nine percent of studies demonstrated improvement in target outcomes. A variety of training components were used in combination throughout the studies, demonstrating a possibility of significant change to medical personnel's abilities for and attitudes about working with patients with neurodevelopmental disorders.  Conclusion: Further research is needed to determine specifically which types of training can affect which target outcomes.

Developing a web-based patient decision aid for gastrostomy in motor neuron disease: a study protocol

INTRODUCTION

Motor neuron disease (MND) is a progressive, incurable disease, characterised by degeneration of the nerves in the brain and spinal cord. Due to the multisystem effects of the disease, patients are faced with many complex, time-sensitive decisions, one of which is the decision on gastrostomy feeding. There are currently no published decision aids (DAs) to support patients making this decision in the UK. This study will develop and pilot a patient DA to provide evidence-based information on gastrostomy placement and feeding that is relevant to people with MND; communicate the risks and benefits associated with each option; check understanding and clarify personal values and preferences, enabling patients to make a decision congruent with their values and appropriate for them.

METHODS AND ANALYSIS

A two-phase process, observing the International Patient Decision Aid Standards, will be used to develop the DA, over 24 months starting January 2019. Phase 1 will use literature reviews and stakeholder interviews and surveys to identify essential content for the DA, and explore the best way to present this. In the second phase, a prototype DA will be developed and revised using stakeholder feedback in an iterative process. Stakeholders will include individuals with MND, their carers and the healthcare professionals working with them.

ETHICS AND DISSEMINATION

Ethical approval for the study has been granted by West of Scotland Research Ethics Service, reference 19/WS/0078. Study findings will be disseminated through academic and non-academic publications, conference presentations, stakeholder websites and social media. A feasibility study will follow to explore the acceptability and practicality of the DA for patients, carers and HCPs in practice and to assess whether the DA shows promise of being beneficial for the intended population.

Communication and cognitive impairments and health care decision making in MND: A narrative review

RATIONALE

Motor neurone disease (MND) is a neurodegenerative disease presenting with progressive weakness of voluntary muscles. For any condition, person-centred health care relies on the sharing of information and a mutual understanding of the person's needs and preferences. Decision making in MND becomes more complex as there is no cure and a high prevalence of co-morbid communication and/or cognitive difficulties.

OBJECTIVE

To identify the reported impact of communication and/or cognitive impairment on patient and carer involvement in health care decision making in MND.

METHODS

A review and synthesis of studies addressing issues of communication impairment and/or cognitive impairment in relation to decision making focussed on MND was conducted. Articles were excluded if they were reviews, case studies, conference papers, or commentaries. To be included studies needed to address issues of communication impairment or cognitive impairment specifically in relation to decision making. Relevant data were extracted verbatim and subjected to content analysis to support the narrative summary.

RESULTS

Seventy-six articles were identified, and 35 articles screened. Six articles met inclusion criteria each describing examples of decision making in MND. There was limited data related to communication and/or cognitive impairment, and the impact these impairments may have on decision making despite recognition that many people with MND may lose verbal communication or develop subtle cognitive impairments. The literature is primarily from the perspective of others.

CONCLUSION

This review highlights that the current body of literature exploring decision making within the MND population presents us with extremely limited insights into the impact of communication and/or cognitive impairments on health care decision making. Extant literature focuses on interventions (namely, ventilation and gastrostomy), the broad process of decision making, or cognitive assessment of decision-making ability. Whilst most studies acknowledge that deficits in communication or cognition impact the decision-making process, this issue is not the focus of any study.

Development of a Digital Decision Support Tool to Aid Participation of Children With Disabilities in Pediatric Rehabilitation Services: Explorative Qualitative Study

BACKGROUND

Building a health care system in accordance with the rule of law requires child-centered care, where children and young people, regardless of ability, are allowed to participate in visits with their health care professionals. As part of an overall project focusing on developing and implementing a digital decision support tool to increase the participation of children with disabilities in pediatric rehabilitation, this study brings new knowledge as to how this specific patient group views participation.

OBJECTIVE

The aim of this formative study was to explore the experiences of children and young people with disabilities concerning increasing their participation in the pediatric rehabilitation services.

METHODS

The formative study had an explorative design, based on a latent qualitative content analysis with an inductive approach. Interviews were conducted with 20 children (6-17 years) and 8 young people (19-30 years) with disabilities about their experiences of participation in pediatric rehabilitation services.

RESULTS

A total of 3 categories emerged reflecting the participants' possibilities of participation in the pediatric rehabilitation services: to feel involved, to feel independent, and to work in partnership. To feel involved meant being listened to and being connected, to feel independent meant being admitted and being enabled, and to work in partnership meant being supported and being able to entrust others with the decision making. With the overall theme moving toward empowerment of children in pediatric rehabilitation, a true feeling of participation can be experienced.

CONCLUSIONS

The views of children and young people with disabilities are that children should be given the prerequisites for empowerment by being allowed to feel involved and independent as well as to work in partnership to experience true participation in the pediatric rehabilitation services. This finding is essential in the design of a digital decision support tool based on the children's needs and perspectives.

Advancing the Delivery of Communication Sciences and Disorders Services Through Research: The Promise of Health Services Research

Purpose

Traditional efficacy research, or research that studies interventions in controlled settings, can be difficult to translate to real-world clinical settings. In this article, we introduce the field of health services research (HSR) as 1 possible tool to aid this translation. HSR is a field of research that examines and intervenes in the use, cost, quality, delivery, organization, and outcomes of clinical interventions and services in the real-world setting. The complexity of the world outside the clinic walls is accounted for in HSR methods and data sources. As such, HSR often requires collaboration of stakeholders, including patients, caregivers, clinicians, and policy makers. These stakeholders are often engaged throughout the research process, from selecting research questions to disseminating results. HSR brings together researchers from multiple disciplines, including sociology, health economics, epidemiology, and implementation science, among others. The outcomes of HSR can inform policy changes both locally and nationally. To clarify the scope and impact of HSR, we present examples of HSR-based research on communication between patients with communication disorders and health care providers.

Conclusions

HSR is a critical tool for clinicians and researchers in the discipline of communication sciences and disorders who are committed to improving the lives and health of persons with communication disorders.

Teaching Medical Students Skills for Effective Communication With Patients Who Have Communication Disorders

Purpose Patients with communication impairments including speech, language, cognition, or hearing disorders face many barriers to communication in health care settings. These patients report loss of autonomy in health care decision making, are at increased risk for medical errors, and are less satisfied with health care than patients without communication disorders. Although medical students receive training in effective patient-provider communication, most of this training assumes patients have intact communication abilities. Medical students and other health care providers are often unprepared to meet the communication needs of patients with communication disorders in health care encounters. The purpose of this study was to assess the impact of a curriculum for training medical students to communicate effectively with patients who have a range of communication disorders. Method Twenty-six 2nd-year medical students volunteered for assessments before and after a required workshop in a class. This workshop included instruction about different types of communication disorders and communication strategies, followed by practice with standardized patients portraying different communication disorders. Outcome measures included a knowledge test, ratings of self-efficacy, and evaluation of students' skills when interviewing standardized patients portraying aphasia and dysarthria. Results Medical students demonstrated significant improvements in knowledge, self-efficacy, and use of recommended communication techniques. Conclusions The curriculum appeared effective in changing medical students' knowledge and skills for working with patients with communication disorders. Equipping medical students to meet the needs of patients with communication disorders is 1 key element for improving the quality of health care for this patient population.

Adults with Communication Disabilities Experience Poorer Health and Healthcare Outcomes Compared to Persons Without Communication Disabilities

BACKGROUND

Persons with speech, language, and/or voice disabilities (collectively referred to as communication disabilities (CD)) represent 10% of the US population, yet their healthcare outcomes have not been described. Generally, research shows that persons with disabilities have poorer health and healthcare outcomes than their non-disabled peers.

OBJECTIVES

To examine the health and healthcare outcomes of persons with CD compared to persons without CD.

DESIGN

Retrospective cohort study of the 2012 National Health Interview Survey, which contained the first supplemental questions on CD. We compared proportional differences in outcomes; logistic and ordered logistic regression assessed the outcome measures across CD categories, controlling for demographics, non-communication disabilities, and chronic conditions. Findings are weighted to permit national inferences.

PARTICIPANTS

Adults (≥ 18 years old) were divided into 4 mutually exclusive groups: people with voice disabilities only; speech/language disabilities only; speech/language and voice disabilities; and people without CD.

MAIN MEASURES

Chronic health conditions; self-rated health; access to care; unmet needs for care; healthcare utilization.

KEY RESULTS

Adults with CD more frequently had ≥ 1 chronic condition (voice 67.9%, speech/language 68.6%, speech/language and voice 79.9%, no CD 50.1%, p < 0.001) and reported fair/poor health (voice 19.5%, speech/language 32.5%, speech/language and voice 48.3%, no CD 11.2%, p < 0.001) compared to those without CD. Adults with CD more frequently utilized healthcare compared to those without CD. However, persons with CD endorsed greater difficulties accessing care than those without CD, including identifying a usual source of care, trouble finding a physician, and delaying or foregoing care (e.g., delayed due to availability of care: voice 26.1%, speech/language 37.2%, speech/language and voice 30.8% no CD 16.1%, p < 0.001).

CONCLUSIONS

Persons with CD are medically complex and experience greater challenges accessing healthcare than persons without CD. Healthcare providers need support and tools to provide equitable care that addresses the medical needs of persons with CD.

A patient in the clinic; a person in the world. Why shared decision making needs to center on the person rather than the medical encounter

Interest in shared decision making (SDM) has increased and become widely promoted. However, from both practical and measurement perspectives, SDM's origin as an outgrowth of patient autonomy has resulted in narrowly conceptualizing and operationalizing decision making. The narrow focus on individual patient autonomy fails in four main ways: 1) excluding several facets of the roles, actions, and influences of decision partners in decision making; 2) focusing solely on the medical encounter; 3) ignoring the informational environment to which patients have access; and 4) treating each encounter as independent of all others. In addition to creating a research agenda that could answer important outstanding questions about how decisions are made and the consequences thereof, reconceiving SDM as centered on the person rather than the medical encounter has the potential to transform how illness is experienced by patients and families and how clinicians find meaning in their work.

IIAM (important information about me): a patient portability profile app for adults, children and families with neurodevelopmental disabilities

PURPOSE

To describe the development of important information about me (IIAM), an application (app) used to communicate and organize healthcare information for people with neurodevelopmental disabilities (NDD).

METHODS

Prior to the development of IIAM version 1.0, households with NDD were selected to participate in a focus group. Respondents (n = 7) were parents of children with NDD. Participants were asked to use a beta version for at least 2 months in day-to-day applications and to complete a questionnaire at the end of the trial.

RESULTS

Over half (57%) of the participants found the beta version to be useful. The greatest limitation in usability was the child's age and literacy level. All participants found the app to be visually appealing and easy to navigate. IIAM was commonly used to communicate information to caregivers, and to facilitate quality interactions between the child and others.

CONCLUSION

Mobile technology has become ubiquitous and has emerged as an important tool in healthcare. New applications could potentially promote accessible, cost-effective and self-managed interventions for the disability community. IIAM is a user-friendly, well-accepted and useful app for people with NDD. The focus group feedback elicited from the beta testing was used to develop the IIAM app version 1.0. However, the sample size in this initial feasibility study is small, and warrants a prospective study that evaluates the overall benefits of this app in improving quality of life and helping individuals with developmental disabilities manage their day-to-day activities. Implications for Rehabilitation Mobile technology has been more ubiquitous in health care and has emerged as a tool in communicating healthcare needs. New applications could potentially promote accessible, cost-effective and self-managed interventions for the disability community. IIAM (important information about me) is a new iOS application that enables adults and children with neurodevelopmental disabilities to organize their medical records, advocate for their healthcare needs, and help overcome communication and time limitations with health professionals and caregivers.

Review of Interventions to Enhance the Health Communication of People With Intellectual Disabilities: A Communicative Health Literacy Perspective

BACKGROUND

Communicative health literacy is a term relating to the range of competencies and capabilities patients bring to the task of seeking information about their health and sharing it with others. This exchange can be problematic for people with intellectual disabilities. The aim of this review was to synthesize findings from interventions designed to improve health communication for people with intellectual disabilities.

MATERIALS AND METHOD

Available evidence was systematically reviewed, and findings from 14 articles were synthesized in a narrative review.

RESULTS AND CONCLUSIONS

Interventions addressed communicative aspects of health consultations, taking into account emotional factors and social context. Questions remain about how such interventions might impact on real-life health consultations and how issues of power might be resolved.

Patient Communication in Health Care Settings: new Opportunities for Augmentative and Alternative Communication

Delivering quality health care requires effective communication between health care providers and their patients. In this article, we call on augmentative and alternative communication (AAC) practitioners to offer their knowledge and skills in support of a broader range of patients who confront communication challenges in health care settings. We also provide ideas and examples about ways to prepare people with complex communication needs for the inevitable medical encounters that they will face. We argue that AAC practitioners, educators, and researchers have a unique role to play, important expertise to share, and an extraordinary opportunity to advance the profession, while positively affecting patient outcomes across the health care continuum for a large number of people.

Prevalence and etiologies of adult communication disabilities in the United States: Results from the 2012 National Health Interview Survey

BACKGROUND

Communication disabilities, including speech, language and voice disabilities, can significantly impact a person's quality of life, employment and health status. Despite this, little is known about the prevalence and etiology of communication disabilities in the general adult population.

OBJECTIVES

To assess the prevalence and etiology of communication disabilities in a nationally representative adult sample.

METHODS

We conducted a cross-sectional study and analyzed the responses of non-institutionalized adults to the Sample Adult Core questionnaire within the 2012 National Health Interview Survey. We used respondents' self-report of having a speech, language or voice disability within the past year and receiving a diagnosis for one of these communication disabilities, as well as the etiology of their communication disability. We additionally examined the responses by subgroups, including sex, age, race and ethnicity, and geographical area.

RESULTS

In 2012 approximately 10% of the US adult population reported a communication disability, while only 2% of adults reported receiving a diagnosis. The rates of speech, language and voice disabilities and diagnoses varied across gender, race/ethnicity and geographic groups. The most common response for the etiology of a communication disability was "something else."

CONCLUSIONS

Improved understanding of population prevalence and etiologies of communication disabilities will assist in appropriately directing rehabilitation and medical services; potentially reducing the burden of communication disabilities.

Silence in the EHR: infrequent documentation of aphonia in the electronic health record

Background

To begin to deliver patient-centered care, providers need to be aware of when a patient has a communication disability and what communication methods to use with the patient. The aim of the study was to describe if and how patients’ communication disabilities are documented within electronic health records (EHR).

Methods

A retrospective manual chart review of all inpatient and outpatient clinical encounter notes within the EHR for patients who had undergone a laryngectomy at Northwestern Memorial Hospital (Chicago, IL) between 2000–2013. We selected patients who had undergone a laryngectomy as the patient population as we were able to easily identify the patients through Common Procedural Terminology (CPT) codes.

Results

We identified 81 patient charts with 7484 encounter notes. Of the 81 patient charts, 58 (72%) had at least one encounter note with a communication notation. Excluding speech-language pathology notes, 1164 (16%) of all encounter notes included some notation of the patients’ communication abilities. We coded the communication notations into four categories. 1) Descriptions of communication abilities appeared in 663 (9%) of all encounter notes, 2) descriptions of communication methods appeared in 590 (8%) of all encounter notes, and the last two categories 3) medical management and 4) referrals to speech-language pathology services each appeared in 148 (2%) of all encounter notes. While all patients had the same type of communication disability, aphonia, providers used 39 different terms and phrases to describe aphonia.

Conclusions

Patients’ communication abilities were infrequently documented in the EHR. When providers did document a patient’s communication disability or method, they used inconsistent descriptions, suggesting a lack of standardized language. Further work is needed to determine how to consistently and accurately document patients’ communication abilities so staff and providers can quickly recognize how best to communicate with patients with communication disabilities.

A research agenda for documenting disability status within healthcare organizations to address disparities in care

Individuals with disabilities are at a greater risk of experiencing healthcare disparities. To address these disparities, healthcare organizations (HCOs) need to consistently and accurately document patients' disability status. Unfortunately, the evidence base does not yet exist to guide HCOs in determining what data to collect or the best method to collect the data. The authors propose a research agenda for developing and administering disability status questions. To determine what data to collect, researchers need to addresses the following challenges: disability is a complex concept, a wide range of types of disabilities exists, severity levels of disability can differ and, finally, patients might use assistive devices or aids to mitigate or ameliorate their disability. Additionally, research is needed to determine the frequency with which to administer questions due to the dynamic nature of disability, and to develop protocols for assessing the most appropriate person to answer disability status questions. Targeted research will lead to disability status questions that accurately and consistently identify individuals with disabilities and produce actionable data that HCOs can use to detect and address potential disparities in care.