20Q: Communication Strategies for Inpatients Who Can’t Talk

From the Desk of Ann Kummer

One of my first patients at Cincinnati Children’s was a 17-year-old boy who had sustained a severe traumatic brain injury (TBI) and had been in a coma for several months. When he began to show consciousness, I was sent to evaluate him. I found that he was not able to speak or move. However, he followed me with his eyes. One of my colleagues suggested that I ask him to answer factual yes/no questions by “eye pointing.” This worked! He could understand speech, but he had no way to express his needs and wants. Later, after he recovered, he told me that he could understand what people were saying during this time, but he felt locked in and frustrated at his inability to communicate.

I have always remembered this patient and thought about how horrible it would be to be in the hospital and not able to ask questions or communicate basic needs. Therefore, I’m so happy that this article is about strategies to help inpatients who can’t talk.

Here is some information about the authors of this 20Q:

Elizabeth K. Hanson, Ph.D., CCC-SLP is an associate professor at the USD Department of Communication Disorders where she teaches graduate courses in AAC, Motor Speech Disorders, Research Methods, and Advanced Communication Science.  Her research interests include AAC and Motor Speech Disorders.  She earned her Ph.D. from the University of Nebraska – Lincoln, and her M.S. from the University of Wisconsin – Madison.  Dr. Hanson practiced as an augmentative communication specialist at the TRACE Center, an AAC clinic in Madison, Wisconsin, and as a clinical educator in AAC at the Speech-Language & Hearing Clinic, University of Nebraska-Lincoln.  

Joanne Lasker, Ph.D., CCC-SLP, focuses her teaching and research on augmentative and alternative communication (AAC) for adults living with acquired neurogenic disorders. She has published numerous papers and chapters related to the assessment and treatment of adults with acquired communication disorders who may benefit from augmentative and alternative communication techniques. Her current research focuses on selecting and creating low-tech and high-tech communication strategies for people living with aphasia. Joanne’s scholarship has appeared in widely read textbook chapters and refereed journals, including Augmentative and Alternative Communication, Journal of Medical Speech-Language Pathology, Clinical Aphasiology, and Perspectives of SIG 12: Augmentative and Alternative Communication. Joanne and her coauthor received the ASHA Leader Outstanding Contribution Award for Speech-Language Pathology, for their article entitled, "Aphasia and AAC: Enhancing communication across health care settings." Joanne has served as Chair of the Department of Communication Sciences and Disorders, the Graduate Program Director for the On-Campus Master’s Program, and the founding Graduate Program Director for the Speech@Emerson Online Master’s program. She is the recipient of the college-wide Spirit of Emerson Award and the Emerson College Alumni Award for Teaching Innovation.

Laura J Ball, PhD, is a retired Professor of Speech-Language Pathology. She currently facilitates AAC coursework at Emerson College and is active in several research projects focused on degenerative neurological conditions. Dr. Ball completed PhD research at the University of Nebraska-Lincoln, with focused interests in AAC and neuromotor speech disorders. She has over 40 years’ experience as a speech-language pathologist, working with persons with complex communication impairments and dysphagia. She has particular research interests in motor-based assessment and treatment and has authored numerous publications on AAC, dysarthria and apraxia.

This is a very good article! It has practical strategies, and even videos, to teach providers ways to help patients who are unable to speak while in the hospital.

Now…read on, learn, and enjoy!

Ann W. Kummer, PhD, CCC-SLP, FASHA, 2017 ASHA Honors
Contributing Editor 

Browse the complete collection of 20Q with Ann Kummer CEU articles at www.speechpathology.com/20Q

20Q: Communication Strategies for Inpatients Who Can’t Talk

Learning Outcomes

After this course, readers will be able to: 

• Identify methods for basic communication with people who are unable to speak in the medical setting.
• Describe how to evaluate patients for immediate and future communication needs.
• Describe how to develop a tool kit of equipment and materials to support communication needs for patients unable to speak in the medical setting.

Introduction

A hospital stay is bewildering at best. Patients who can’t speak experience immense frustration, isolation, and fear. They can’t communicate basic needs and wants, can’t ask questions about their condition, prognosis, and treatment, and can’t fully participate in directing their care (Fried-Oken, 2001; Marshall & Hurtig, 2019; Zaga, Berney, & Vogel, 2019). The inability to communicate when hospitalized increases patient suffering, duration of hospitalization, and preventable mistakes (Hurtig, Alper, and Berkowitz, 2018). 

Beyond being life-threatening, the consequences of stymied patient communication can be expensive.  Hurtig, Alper, and Berkowitz (2018) calculated the cost of “adverse events” reported to regulatory agencies on an annual basis of more than $29 billion.  

The new inpatient on your caseload may be experiencing newly acquired communication limitations due to trauma, neuromuscular impairments, or cognitive-linguistic impairments, etc. For some, the experience of speechlessness will occur as a product of a planned medical procedure, such as laryngectomy/glossectomy.

Regardless, these individuals are vulnerable.  Very likely, they are confused about what occurred to find themselves in their situation and frustrated by their newly limited communication.  The pressing question is: “How do we help this patient communicate?!”

1. This patient can’t communicate! How can I get basic communication going for my patient?

Triage: because you urgently want to establish an effective means of communication, focus on now.  Try to determine the patient’s preferred language. Speak directly to the patient and position yourself at eye level, if possible.  Support comprehension with a visual support that you show them and point to while speaking to them. Wait patiently and quietly for the patient to respond.  Maintain eye contact, or keep watching them for subtle changes in affect, eye gaze, or a small movement that might indicate a response.  Keep statements and questions short. Avoid convoluted questions.  Even if the patient appears to be unresponsive, don’t give up. If you must leave after a period of time and they haven’t responded, tell them you have to leave and that you will be back to keep working with them, so they don’t feel you’re giving up.

Initial assessment questions include:

• What is the patient’s preferred language? Do you need an interpreter?
• Is there information about sensory (i.e., vision and hearing) status?  Where can you obtain it?  Do you need to screen vision and/or hearing?
• What levels of alertness are noted and when? How long do alert times last?
• Is the person attempting to communicate? If yes, when (e.g., during times of day, specific procedures, with certain people)?
• Is there information that you want to share with the person (e.g., status of health, what happened, family member details, healthcare decision-making, plans, consoling/easing worries)?
• Has anyone identified any successful methods for communicating with the person? If yes, get details (e.g., yes/no with thumbs up/down, smile/grimace, eye gaze pointing). What movements or reactions happen consistently or sometimes? 

Find examples of visual comprehension supports and communication displays that are free to download and use at the Patient-Provider Communication website.

This information provides a rudimentary idea of the person’s retained communication and access/physical movement skills and their communication needs. This is an excellent starting point.  From here, you can move on to establishing their “yes” response. 

2. How do I determine a “yes” or “no” response from the patient if they can’t nod their head or say “yes?”

Explain to the patient, for example: “We’re going to figure out a way for you to communicate with us and your (family/loved ones/friends/visitors).  Let’s start with yes or no questions.  How can you tell us  “yes.” (Wait and watch closely as the response might be very subtle.) “Have you tried this with anyone else?”  When you observe a behavioral response, confirm it, for example: “I see you wiggled your left foot when I asked that question.  Is that a good way to tell me “yes?”  Can you do it again?” 

Some possibilities for a movement to indicate “yes” include:

• Look up / up right / up left, etc.
• Thumbs up
• Raise finger/hand/arm/toe/foot/leg
• Purse lips
• Click tongue
• Stick out tongue

Further questions to verify the “yes” response should be limited to those with known answers!  Otherwise, you can’t be sure the patient understands the task or the question or is intentionally responding!  You can ask questions like “Is your name _____?” “Am I wearing glasses?”  Remember, you’re not assessing orientation at this point.  Stick to known responses!  Keep questions short and straightforward. No confusing wording.

It will take trial and error to identify the patient’s reliable “yes” response.  Don’t worry about movement for “no” right now.  One reliable movement may be all the patient can do!  Tell them: “If the answer is ‘no,’ then don’t respond at all.”

Make sure you provide adequate “wait time” for the patient to respond to your questions - both during the evaluation process and while interacting. Thirty seconds is not unusual for a response time. During your interactions, position yourself at eye level and make sure your affect is pleasant, patient, and affirming.  Ask the question and then stop talking!  The patient may need time to decide the answer and/or to make the movement happen. 

When you’ve determined a reliable “yes” response, it must be communicated to other providers, family members, and other visitors.  Use signage to describe the patient’s current communication in multiple locations as allowed by your facility.  If possible, post a laminated sign with eye-catching colors that explains how to communicate with the patient and how to recognize their “yes” response.

Once the patient has a reliable response, you should measure the time it takes for them to respond across a few trials so you can document it. Think about it, if you can share with other providers that it takes the patient an average of 25 seconds to consider the question and respond, you may be able to prevent miscommunications caused by impatient communication partners. 

Eventually, you will need to add to this initial repertoire with a way to communicate “no,” “maybe,” “I don’t know,” “later,” etc.  The immediate need is one reliable response for “yes.”  You’ll build on that response in the near future.

3.  Are there more basics I need to remember in this situation?

Yes. Remember, the patient has countless caregivers in and out of their room at all times of the day and night and they won’t remember everyone’s name.  You must introduce yourself and your reason for being there every time.  A simple introduction, pointing to your name badge (make sure it’s visible), and a statement of your role:  “Hi, I’m Susan the speech therapist. I’m here to help you communicate.”  Educate other hospital staff to provide this basic information and communication support as well.

4. OK, basic communication is in place. Now, how do I complete the actual evaluation?

• For now, focus on immediate needs. What do you observe? Are they awake and aware, and persistent enough to engage in communication with others?
• Can the patient see and hear you? Make sure that existing supports prior to hospitalization are available and in place (e.g., corrective lenses for vision, hearing aids, other assistive listening technology).
• Try to determine the times during each day when the person is most awake and desires communicative interactions.
• Speak with staff and family/carers about how interactions are changed and what specific needs are present. Integrate information from family interviews and input from other providers into the process. What have they tried?  What has worked or not worked?
• Do a brief assessment of motor skills, in collaboration with OT/PT when possible, to identify optimal body part functions for selecting messages (e.g., fingers/hands, head, eyes, toes/feet).
  • Consider the patient’s position and what movement is possible given their position.  Is it possible to adjust their position to allow more movement for accessing a communication system?
• Try a short, written task to evaluate handwriting and written language for communication. If handwriting is not functional, try a short, written language communication task with a regular or onscreen keyboard on a tablet. If the person has difficulty spelling or recognizing print, try the task with images or visual scenes (i.e., relevant pictures of people, activities, and events).
• Is the patient unable to speak because they are intubated or on a ventilator? Determine if they can effectively use and tolerate a speaking valve if a trach is in place.
• Are they proficient in the same language that the team is speaking? Try interactions in their primary language (i.e., L1) and English. Make sure that messages are available in the person’s preferred language and modality.
• Do they seem unable to think of the words they want to say? Try an aphasia screening test or complete the MCST-A (Lasker & Garrett, 2006) to determine the communicator “type” to optimize current communication.   

Incorporate the following into your approach and initial interviews, once you have established basic communication:

• Avoid assuming the person’s gender, type of spouse (e.g., husband or wife), preferred pronouns (e.g., he, she, they).  Instead, ask! 
• Include these questions in your process: “What is the one thing I need to know about you?” and, “What is the most important thing I need to know about you or your spouse, while we’re working together?”
• Know how to request appropriate interpreters to support the person’s communication.
• Keep a list of communication strategies that may be intermittently effective and ineffective but have potential based on recovery of specific skills.

5. What if I get a referral for a swallowing evaluation that doesn’t include communication?

You could advocate to establish a standard order for “speech-language pathology” services that includes wording for speech, language, and swallowing services. Often readily available for inclusion in the electronic medical record system, this is generally preferred by clinicians as long as the order is accepted by the necessary funding sources.

The following CPT codes are useful:

• Billing for the non-SGD evaluation procedures described here is included under 92523--Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (e.g., receptive and expressive language). (See: ASHA Medicare Coding Rules for SLPs)
• Billing for the non-SGD treatment services described here is included under 92507--Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual.
• Billing for caregiver training, may become a time-based service, without the patient present, in 2024.  This would be a first for CMS and would make a big impact on the services provided by SLPs to inpatients who can’t talk. Watch for updates on this important change in the new year!

A second parallel approach is to educate administrative staff and ordering providers about the importance of speech-language services. Written templates of sample orders are often helpful. This can be quite effective if most providers are considering assessment/treatment of swallowing in isolation. A reminder of the “Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals” outlined by the Joint Commission is an excellent resource to emphasize the importance of effective communication for patient safety and satisfaction.

6.  What else do I need to keep in mind as I approach this communication assessment?

The concept of “communication vulnerability” is now recognized as a description of patients for whom difficulty expressing themselves and/or understanding communication is challenged for many overlapping reasons (Blackstone, Beukelman, & Yorkston, 2015).  Some examples:

• A person who is not fluent in the primary language may be hospitalized because of a stroke resulting in aphasia.
• A person with spastic cerebral palsy causing severe dysarthria who is brought to the ER without her AAC system and, therefore, is unable to answer questions from hospital staff and share her pre-existing medical conditions. 
• A patient who is intubated and breathing with a ventilator and whose language is different from that of the medical team.
• A patient with diverse cultural experiences who presents with cognitive-communication deficits resulting from trauma, injury, or disease.
• A person who is gender-nonconforming and is unwilling to disclose pertinent, personal information.
• A patient who is unable to communicate because of diffuse symptoms related to “brain fog” or “chemobrain.”
• A person who is less responsive due to medications related to or unrelated to their hospitalization.

7.  This patient is here for a procedure that will leave them unable to speak for a temporary period. We anticipate a return of speech eventually.  Is there a purpose for AAC in this case?

Absolutely!  Patients have a right to communication at all times, regardless of whether their typical communication modalities are disrupted temporarily or permanently. That means the SLP should be involved in preparing the patient for the procedure that will leave them temporarily unable to talk.  Discuss options for alternative communication and work with the patient to choose the strategies that they are comfortable with.  For example, writing on a notepad or erasable board may work in some situations, however, another alternative might be a communication board with topic words and the alphabet for the patient to point to. 

For communication to be successful, communication partners must be prepared to accommodate alternate modes of communication.  So, along with preparing the patient, pre- and post-procedure staff need training to support the patient’s communication.  The benefit to this type of training for staff is they can generalize it by anticipating the need to support alternate communication among patients on their caseload. 

Here are a few low-tech strategies for successful communication when speech and other movement is impeded.  A few materials are needed (see links for resources) and the patient and communication partners need training:

1. An eye-transfer or “e-tran” board looks like a frame with the middle cut out.  The communication partner holds the frame so the patient can make eye contact with them.  With that stance, the patient can clearly point, or indicate, to sections of the frame with their eyes.  Letters of the alphabet or phrases may be added to the sections for the patient to indicate with eye gaze.  Here are some e-tran demonstrations and resources:  How Do You Make an E-Tran Board? Free PDF - ADULT SPEECH THERAPY, ETRAN- Eye Transfer Systems. See also Alphabet Boards, Using an E-tran frame (eye pointing) with text, AAC Eye-gaze Flipbook
2. Eye-linking may be a precursor to e-tran when the patient’s strength and movement is too limited for looking at the corners of a display.  In this case, the communication partner holds a transparency with letters, words, or phrases so they are looking at the patient through the transparency.  It’s easier for the patient to look at the intended target that way and the partner moves the transparency so they are “linking” their eyes through the target.  Here are some eye linking demonstrations and resources: Using Eye Pointing for Communication using Eye link  Eye link board with symbols,  Supporting Communication of Individuals with Minimal Movement (Fager & Beukelman) 
3. Partner-assisted scanning needs only a “yes” response (see above) from the patient.  The communication partner holds a display with letters, words, or messages where the patient can see it.  Then the partner announces each item (or row, column, or group) while pointing to it and watching the patient for the “yes” response.  Here are some eye linking demonstrations and resources: Partner-assisted scanning,  Video of the Week: Getting Familiar with Partner-Assisted Scanning, AAC Eye Point Training with Partner Assisted Scanning

In all these methods, the responsibility falls to the communication partner to provide the opportunities to communicate, hold the materials, maintain a calm and methodical interaction style, and verify the patient’s message.  The rate of communication using any of these methods is very slow, but it is imperative that the communication partner respects and supports the patient’s right and need to communicate.

8. This patient can talk right now but is here for a procedure that will leave them unable to speak for a long time.  It is even possible that speech might not return.  How do I help them prepare for this drastic change in communication ability?

Facing the possibility that speech may be lost forever, as the result of a procedure or condition, should be addressed with sensitivity but directness.  It may help a patient to be involved with planning for post-procedure communication and it may alleviate some of the anxiety of not knowing what to expect after discharge.   Emphasize that loss of speech is expected to be temporary (if that’s the case) and that they will need a different way to communicate in the meantime.  Involving the patient in developing and learning to communicate with an alternative system may help them feel empowered to deal with the changes they face as a result of their hospitalization and procedure.

9. How can I help other team members understand how speech, language, and cognition contribute to communication difficulties in the inpatient setting?

Here are a couple of approaches.  One might work better than the other in your situation but don’t be afraid to use both or combine them to come up with a third approach that works better for you!

1. The first approach is the “in-service” method.  Offer to provide a short training session for staff (many organizations offer these in the form of “brown bags,” which occur during a lunch break).  Set the scene by describing a specific situation, such as a patient who comes in for an appointment and has trouble following directions.  Describe options for communication, such as writing down key words or a couple of different options (Wood, Lasker, Siegel-Causey, Beukelman, & Ball, 1998) on a notepad or small whiteboard. Then demonstrate a specific strategy, perhaps with someone in the audience.  You want to demonstrate how the strategy is worked into their typical communication exchange with the patient.

Cover in-service topics such as:

• How to help patients communicate a variety of messages at crucial times.
• Changes in status, context, topics, or partners 
• Frustrations - need for persistence and patience.
• Need to keep teaching new partners over time - as staff changes.
• Something quick, efficient, nonfatiguing, that won’t break down is needed.
• There are challenges associated with patient access, awareness, and timing of interventions.

2. The second approach involves building on what they’re already doing successfully.  For this you could start by asking the provider to give an example of when they get really frustrated with communication.  Then, ask them what they’ve tried and how well it worked.  Often the best solutions are those that people develop in the moment.  You might just need to encourage them to keep doing it.  You might also see a way to add to what they’re doing to make it more effective.

Also, if you can create communication opportunities that result in success for your co-workers and patients, there may be more buy-in regarding the resources and interventions you offer.  Successful communication is always the best reward, so if you can arrange for them to try out a strategy right away, and be there when it happens to offer guidance, you can set them up for success and that will engender more motivation to keep doing it.

If you want communication partners to use something, like a dry-erase board or notebook, try to have those tools available for them during the lesson and allow them to take it with them to use.  That will avoid the excuse that materials aren’t available when needed.

10. The patient’s family is supportive, but they don’t understand what you mean by “alternate forms of communication.”  Do you have some tips for introducing the idea for communicating with their loved one?  

Remember: empathy and plain language.  Plain language is written or spoken in a way that is understandable to the person receiving new information (plainlanguage.gov).  Short factual explanations of the patient’s condition and how it may change can help family members understand the altered communication that results.  Follow the factual information with modeling to show them how to interact with their loved one.

Teach them some specific visual and written techniques to support conversation with their loved ones.

Here are a couple examples:

• Augmented Input Conversation Strategy is when a partner writes down key words, pictures, information to support the understanding of a communication partner with receptive language problems (Wood, Lasker, Siegel-Causey, Beukelman, & Ball, 1998)
• In the Written Choice Conversation Strategy, communication partners write out choices and use number scales to help people with limited expression communicate by pointing to options. Families may also be taught Yes/No approaches, in which they pose a question and then offer a “tag” at the end, requesting a yes/no response from their family member (Garrett, Lasker, King-Fischer, 2020)

11.  How do you work with a patient who only wants to talk and won’t try other communication modalities?

Although SLPs learn to identify and address multiple modalities, patients often persist in viewing speech as the ONLY way to communicate.  They may also feel that not having speech therapy indicates you’ve given up on helping them talk again. That could create a power struggle between patient and SLP - and you don’t want that to happen!

Multimodal communication strategies don’t have to be front-and-center in the treatment plan. Acknowledge their desire to communicate and reassure the patient that the focus is on making speech as good as possible while addressing other ways of communication at the same time. You can begin sessions with speech stimulability techniques and simply guide the patient to respond to you or ask questions using a different modality.  Don’t call attention to the strategies, just use them.

Remember, the first “A” in AAC is for “augmentative.”  That means speech and other communication modalities are not mutually exclusive.  Often, if a speaker provides a first-letter cue (i.e., points to a keyboard or display showing the alphabet) while saying a word, the communication partner can understand it.  This strategy is known as “alphabet supplementation, Hanson, 2014; Hanson, Beukelman, & Yorkston, 2013). The letter board may be printed in a format the patient prefers (e.g., A-B-C order or Q-W-E-R-T-Y order) in any size needed.  Laminating the letter board will keep it from becoming wrinkled and torn.  Ready-made alphabet supplementation displays are available for free download on the Patient-Provider Communication website mentioned earlier. These may also be used to spell entire words.

12. How do you work with family members who only want their person to talk and don’t want you to introduce other communication modalities?

Sometimes family members simply don’t realize that there are other ways for their person to communicate and are agreeable once it’s explained to them.  Successful communication in itself can be a valuable learning experience and a strong motivator for both patient and family members. 

If the family member/s continue to focus on speech, try the same approach described above.  That is, reassure them that speech is supported in the therapy plan.  It may also be useful to help them identify all the non-speech modalities they use when communicating.

13. Sometimes, others (e.g., nursing staff) have already come up with some communication strategies for a patient.  Am I shirking my duty if I’m not always the lead on patient communication for the team?

In healthcare settings, the SLP is a critical member of the healthcare team designing ready to use, effective communication strategies for patients who are nonverbal (Downey & Happ, 2013). Frequently, nursing leadership on the team may begin this process by determining basic methods for patients to communicate “yes” and “no.” They may create strategies at intake and communicate these strategies in report to each other. Medical members of the team may then write a referral reaching out to SLPs for guidance on more specific plans for extensive communication. When this occurs, we SLPs take the lead on devising effective communication strategies, teaching partners specifically how to use strategies, and checking in periodically to ensure that strategies are working effectively.  Bottom line: If others on the healthcare team are already incorporating alternate strategies for communication with the patient, the SLP’s job is to champion those efforts.  This allows the SLP to build on those strategies to expand current communication skills and develop future communication strategies. 

14. What supplies and materials should I have available to support communication strategies for inpatients?

It is much easier to quickly address communication needs for a patient when you have the necessary tools and materials you need!  Consider putting together a “Communication Toolkit” binder, bin, or bag to keep in a location where everyone on the floor or wing has access.  The initial creation of these materials should include staff training to support others in identifying and implementing communication solutions quickly, without waiting for you to come in response to a request or order.

The following list of suggested supplies and materials for a Communication Toolkit was compiled by the authors and should be modified for your work setting:

Office supplies for the Communication Toolkit:

• Small dry-erase boards and attached markers
  • Useful to write down key words to support comprehension, offer choices, and allow for written messages if the patient is able
• Medium-sized packages of sticky notes for temporary posting of instructions, reminders, messages
  • Follow up with something less transient because we all know how those sticky notes tend to lose their “stick” and flutter to the floor after a while!
• Clear acrylic clipboards
  • Useful to create quick e-tran (eye-transfer) communication boards or eye-linking boards.
• Erasable markers
• Sharpie(permanent) markers
• Note pads - various sizes
• Ink pens and pencils
• Double-sided tape
• Regular (clear) tape

Off-the-shelf supplies to purchase:

• Boogie Boards (reusable writing tablet that doesn’t require ink)

Free downloads:

• The Patient-Provider Communication website offers an array of free, downloadable communication displays that may be printed and laminated for patient use.

15.  Can I just order a bunch of those pre-made communication boards and hand them out to patients and/or staff to take care of this issue?

Pre-made communication boards are very useful in some situations.  The Patient-Provider Communication website (https://www.patientprovidercommunication.org/) is devoted to this topic of communication between patients and their healthcare providers and there is a section where we can download free communication displays. After we have established a clear method for physical access, such as pointing with the finger or eyes,  and an agreed upon, readily understandable yes/no response, patients may benefit from prepared materials to communicate specific messages.  Other sources, such as manufacturers of speech-output devices, also provide free communication display downloads that may be appropriate for a medical setting. 

While many messages on these tools are applicable, it is important to include some customized, personally relevant messages for the patient’s specific situation.

16. What if the patient needs more specific, extensive, or personalized communication?

It is possible that some of our patients will benefit from strategies to support the formulation of more lengthy, novel communication – messages that cannot be accessed immediately from existing external prestored message systems, such as a medical phrase board.  In planning for more individualized communication, we typically explore our patient’s capabilities in the areas of language, cognition, and motor access. In addition to ensuring that the patient is awake and aware enough for lengthier message generation, we try to learn more about our client’s language skills by asking some of the following questions:

• Are they able to use the alphabet to spell out words or message phrases effectively?
• Can they combine letters and words to create longer messages?
• Can they grasp the concept of “encoding” by which letter or number codes may represent longer utterances?
• Do they have a clear, reliable, non-fatiguing method of accessing specific message components to combine?
• If low-tech eye gaze strategies are to be implemented, are the instructions clear for partners so that messages may be co-constructed effectively?

Based on the responses to these questions, we can then introduce trials with letter boards arranged either in QWERTY, alphabetic, or other formats. (Again, the Patient-Provider Communication website has a variety of pre-made letter boards in various arrangements, available as free downloads.

For some patients, we need to explore how they might assess more long-term solutions when we suspect that they will be unable to speak for a protracted period of time. In these situations, we anticipate that we will use a more extensive AAC-assessment process.

17. Do I have to have some of those expensive computerized speaking devices (i.e., speech-generating devices or SGDs) for patients to use or can I just use a tablet computer with an AAC specialized app?

AAC apps have dominated the market for alternative forms of communication since they started appearing with the introduction of the Apple iPad product. More and more facilities now assign specific tablets to their staff or have a variety available for use with patients.  Sometimes the patient or a family member already has a tablet or smartphone capable of supporting AAC apps. These combinations of specialized AAC apps and a tablet device have been tremendously helpful and have filled a niche for some hospital patients with AAC needs. However, sometimes the patient’s technology needs reach beyond the app/tablet combo.

Perhaps one of the most challenging aspects of providing AAC in an acute setting is ascertaining the patient’s most reliable method of accessing the system. There certainly are many more ways to access AAC messages besides the touch of a finger, but determining what works is not obvious or straight-forward. Incapacitated patients may find themselves temporarily or permanently restricted by limited movement that interferes with voluntary movement of fingers, hands, or arms.  These situations require more extensive evaluation to determine what will work best in the short term and the long term.  Patient capabilities will change (improving or degrading), so their communication system needs to evolve accordingly.  Bottom line: Don’t give up. There is always a way for the patient to interface with the AAC system.

18. If my patient is going to need an expensive, computerized speech-output device, who pays for it?

You may not have enough time to complete an evaluation and finish the extensive paperwork needed for a speech-generating device during a patient’s time as an inpatient.  However, this question may come up and you can provide explanations and guidance to make the future less of a mystery.  There are many funding sources for speech-generating devices, including private insurance, Medicare and Medicaid, Vocational Rehab, and sometimes people will pay out of pocket.  This is not to say there is guaranteed funding, however finding funding to pay for an SGD is realistic.

If you recommend that the patient be evaluated for an SGD, you can start the process by providing documentation of the patient’s communication skills and strategies during their inpatient stay.  Report on their stimulability and the communication systems and strategies presently in place.  Also, document things like literacy level, changes in cognitive-linguistic skills during their time as an inpatient, and motor skills related to alternative access of an AAC system.

19. What do I do if I give the patient a communication board or tablet and they don’t use it?

Along with providing appropriate communication tools, the SLP needs to do what we do best: Help the patient learn these new modes of communication.  Think about it:  You can’t give a person a tennis racket and expect them to go straight to Wimbledon without practice and you wouldn’t expect to hand a violin to a person with no experience and expect to hear them play Vivaldi. So, teach them to communicate using the AAC system you’ve developed.

Besides direct instruction about how to use the system, the patient needs opportunities to communicate with it. Communication opportunities that support success should be the focus of your therapy sessions.  A few ideas for communication opportunities include: 

• Communicating with visitors
  • Providing information, asking partner-focused questions, small-talk, greetings, and closures
• Communicating with other providers/therapists
  • Developing and learning to convey messages and questions to participate in managing their care
• Requesting help with pain or discomfort
• Communicating about end-of-life care, questions, and preferences

Don’t forget: The communication partners need to learn how the new communication system works and what their role is when communicating with the patient.  Use written instructions, explanations, and model the communicative behavior you want partners to adopt when communicating with the patient.

Instruction for partners should always include:

• Make eye contact and try to be on the same level as the patient (e.g., sit next to the patient’s bed rather than standing and talking down to them).
• Provide wait time by allowing the patient time to process what you have communicated and to formulate a response.  It’s important for the partner to keep attention focused on the patient and maintain friendly body language and facial expressions to avoid sending the message that you’re impatient while the patient processes and formulates.
• Determine the patient’s preference for whether the communication partner can guess or complete a message.  Some communicators are comfortable with that, while others are not.
• Carry something to write on (e.g., a notebook, dry-erase board, Boogie board) to offer written choices for communication and to display information.  Think about it: Written information doesn’t vanish, which can help when the patient’s working memory is challenged.

20. How do I know that the strategies I am teaching the patient, the family, and the team are effective? 

Medical settings use a number of different global outcomes measures, some of which include communication metrics and others that do not (e.g., NOMS, FACS, JCAHO). In addition,  the Communicative Participation Item Bank (CPIB): Item bank calibration and development of a disorder-generic short form - PMC (Baylor, Yorkston, Eadie, Kim, Chung, & Amtmann, 2013) is an assessment tool with a generic short form that may be added to existing measures to help round out outcomes data reporting in terms that are familiar to those who conduct those assessments.

The reader should find out which evaluative organization is used by their facility. This is where these communication outcomes fit.  Be sure those in management and administration see your data as it demonstrates productivity and effectiveness of SLP services in the realm of communication disorders. 

Resources

ASHA Medicare Coding Rules for SLPs: Bookmark this for future reference. https://www.asha.org/practice/reimbursement/medicare/slp_coding_rules/

Boogie Boards:

https://myboogieboard.com/collections/live-all-products/products/boogie-board-basics-writing-tablet

Communicative Participation Item Bank (CPIB): Item bank calibration and development of a disorder-generic short form:

            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4377222/

Eye-Linking Tutorials and Resources:

1. Using Eye Pointing for Communication using Eye link
2. Eye link board with symbols
3. EyeLink system in action
4. Supporting Communication of Individuals with Minimal Movement (Fager & Beukelman) 

E-tran Display Tutorials and Resources:

1. How Do You Make an E-Tran Board? Free PDF - ADULT SPEECH THERAPY
2. ETRAN- Eye Transfer Systems. See also Alphabet Boards
3. AAC Eye-Gaze Flip Book (e-tran)
4. Using an E-tran frame (eye pointing) with text

Partner-Assisted Scanning Tutorials and Resources:

1. Partner-assisted scanning
2. Video of the Week: Getting Familiar with Partner-Assisted Scanning
3. AAC Eye Point Training with Partner Assisted Scanning

Patient-Provider Communication website – a great resource with information and free, downloadable communication displays for many different circumstances: https://www.patientprovidercommunication.org/tools-and-resources/communication-tools-and-materials/

The Multimodal Communication Screening Test for Persons with Aphasia (MCST-A) is a free download that can be printed and used with inpatients who can’t talk.  It is easy to assemble and can be used with more than just people with aphasia: https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=3b71f7a07aec26f32f47617c4da3b45d699bf3e5

References

American Speech-Language-Hearing Association. (2021). Medicare CPT coding rules for speech-language pathology services. Retrieved July, 2. https://www.asha.org/practice/reimbursement/medicare/slp_coding_rules/

Baylor, C., Yorkston, K., Eadie, T., Kim, J., Chung, H., & Amtmann, D. (2013). The Communicative Participation Item Bank (CPIB): Item bank calibration and development of a disorder-generic short form. Journal of Speech, Language, and Hearing Research, 56(4), 1190-1208. 

Blackstone, S. W., Beukelman, D. R., & Yorkston, K. M. (2015). Patient-provider communication: Roles for speech-language pathologists and other health care professionals. Plural Publishing.

Downey, D., & Happ, M. B. (2013). The need for nurse training to promote improved patient-provider communication for patients with complex communication needs. Perspectives on Augmentative and Alternative Communication, 22(2), 112-119.

Fried-Oken, M. (2001). Been there, done that: a very personal introduction to the special issue on augmentative and alternative communication and acquired disorders. Augmentative and Alternative Communication, 17(3), 138-140.

Garrett, K.L., Lasker,J.P., & King-Fischer, J. (2020). Chapter 15: AAC supports for adults with severe aphasia and/or apraxia of speech. In D.R. Beukelman & J.C. Light,  Augmentative & Alternative Communication: Supporting Children and Adults with Complex Communication Needs (5th ed., pp 553-604). Baltimore: Paul H. Brookes Publishing Co., Inc.

Hanson, E. K., Beukelman, D. R., & Yorkston, K. M. (2013). Communication support through multimodal supplementation: A scoping review. Augmentative and Alternative Communication, 29(4), 310-321.

Hanson, E. K. (2014). My client talks! Do I still need to consider AAC in my treatment planning? Speech supplementation strategies: AAC for clients who talk! Perspectives on Augmentative and Alternative Communication, 23(3), 124-131.

Hurtig, R. R., Alper, R. M., & Berkowitz, B. (2018). The cost of not addressing the communication barriers faced by hospitalized patients. Perspectives of the ASHA Special Interest Groups, 3(12), 99-112.

Joint Commission. (2010). Advancing effective communication, cultural competence, and patient-and family-centered care: A roadmap for hospitals. Joint Commission. (https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/health-equity/aroadmapforhospitalsfinalversion727pdf.pdf?db=web&hash=AC3AC4BED1D973713C2CA6B2E5ACD01B)

Lasker, J. P., & Garrett, K. L. (2006). Using the Multimodal Communication Screening Test for Persons with Aphasia (MCST‐A) to guide the selection of alternative communication strategies for people with aphasia. Aphasiology, 20(02-04), 217-232.

Marshall, S., & Hurtig, R. R. (2019). Developing a culture of successful communication in acute care settings: Part I. Solving patient-specific issues. Perspectives of the ASHA Special Interest Groups, 4(5), 1028-1036.

Wood, L., Lasker, J., Siegel-Causey, E., Beukelman, D., & Ball, L. (1998). Input framework for augmentative and alternative communication. Augmentative and Alternative Communication, 14(4), 261-267.

Zaga, C. J., Berney, S., & Vogel, A. P. (2019). The feasibility, utility, and safety of communication interventions with mechanically ventilated intensive care unit patients: a systematic review. American Journal of Speech-Language Pathology, 28(3), 1335-1355.