Stephanie Fowler

Funding Project

I. Demographic Information
Patient's Name: Tammy Doe
Social Security #: 000-00-0000
Date of Birth: 3/6/72
Phone Number: 610-555-5555
Address: 4483 Stewart Lane
Bethlehem, PA 18020
Patient's Primary Contact Person: Dan Doe
Relationship to Patient: Spouse
Phone Number: 610-555-5555
Medical Diagnosis: ALS
Date of diagnosis: March 1998
Insurance: Medicare
Number:123456
Date of Evaluation: 11/15/14
Physician: Debbie Houser M.D.
Phone Number: 570-555-5555
Speech-Language Pathologist: Stephanie Fowler
Phone Number: 609-425-2135
Proposed funding report for SGD: DynaVox Maestro
II. Current Communication Impairment
A. General Statements
Patient exhibits severe dysarthria due to ALS, characterized by a speech rate of less than 50
words per minute. Speech intelligibility is less than 20 percent in all contexts. The patient is
currently functioning in ALS speech stage 4. Due to the progressive nature of this disease,
speech is not projected to improve and will continue to deteriorate. The patient will require the
use of a SGD throughout the course of this disease.
B. Comprehensive Assessment
1. Hearing Status: The patient possesses the hearing abilities to effectively use a SGD to
communicate functionally.
2. Vision Status: The patient possesses the visual abilities to effectively use a SGD to
communicate functionally.
3. Physical Status: The patient uses a tilt in space Permobil wheelchair for mobility both inside
and out of the home. The patient utilizes a mini joystick to drive the wheelchair. The patient has
no movement below the neck, except for being able to control the mini joystick with her right
hand. The patient will access the SGD through the joystick seeing as this is the only functional
movement the patient has. The patient possesses the physical abilities to effectively use a SGD
and required accessories to communicate.
4. Language Skills: The patient does not have any deficits in the area of receptive language, as
seen in the administration of the Western Aphasia Battery and in informal assessment measures.
The patients reading and spelling skills are intact. The patient is capable of independently
formulating messages using language.
5. Cognitive Skills: The patients cognitive and problem solving skills are intact, as demonstrated
in performance of the Western Aphasia Battery and informal assessment measures. There are no

deficits in memory or attention. The patient possesses the cognitive/linguistic abilities to

effectively use a SGD to communicate and achieve functional communication goals.
III. Daily Communication Needs
A. Specific Daily Functional Communication Needs
1. The patient needs this device to be able to communicate physical needs (i.e, food, pain, etc.).
A SGD is essential for allowing the patient to communicate in emergency situations, direct
caregivers, and advocate for herself in necessary situations.
2. The patient lives at home with her husband and two children. A SGD is necessary to interact
with family, communicate with physicians at frequent appointments, and being able to
communicate over the phone to keep in touch with family members.
3. A SGD is essential for the patient to be able to adequately communicate needs for medical
care. Due to the nature of the progressive nature of this disease, the patient needs to be an
integral part of the decision making team and to be able to effectively communicate wants and
needs.
B. Ability to meet communication needs with non-SGD treatment approaches
The patients daily functional communication needs cannot be met using natural communication
methods or low-tech/no tech AAC techniques because the patients only functional use of
extremities is in her right hand. The patient does not have enough control to use this hand to
write and writing is not a natural mode of communication. The patients speech is unintelligible.
The only functional way for the patient to communicate is through a SGD. The individual is
capable of using assistance with a scanning technique through a caregiver and a letter board, but
this does not allow the patient to independently communicate. The use of other devices such as
text to speech key boards have been considered, but these options have been ruled out due to the
patients physical status.
IV. Functional Communication Goals
Short Term Goals:
The patient will communicate pain to the caregiver 100% of the time. This goal will be met
within six weeks of obtaining the device.
The patient will communicate physical wants and needs (i.e, food, exhaustion, etc.) to the
caregiver 100% of the time. This goal will be met within six weeks of obtaining the device.
The patient will communicate medical wants and needs to physician 100% of the time. This goal
will be met within six weeks of obtaining the device.
The patient will express thoughts in conversation with 100% accuracy. This goal will be met
within six weeks of obtaining the device.
The patient will communicate effectively over the phone 100% of the time. This goal will be met
within six weeks of obtaining the device.
Long Term Goal:
The patient will be able to independently communicate wants, needs and thoughts in all settings
independently.
V. Rational for Device Selection

This patient requires a speech generating device with alternate access methods, an eye gaze
installation option, and accessories such as a wheel chair mount to meet the patients functional
communication goals. The device chosen is the DynaVox Maestro. This device was chosen
instead of the DynaVox Xpress and DynaWrite 2.0. The DynaVox Xpress was ruled out due to
the fact that the access method is through hand swipes. The patient does not have enough control
to use the device in this manner and no other access methods are available. The previously stated
rationale is why the DynaWrite 2.0 was also ruled out. The DynaWrite 2.0 is accessed through a
keyboard. The patient would not be able to access the device in this manner. The DynaVox
Maestro can be accessed through the joystick that the patient currently uses on the wheelchair.
This device can be mounted to the wheelchair that the patient is currently using. The DynaVox
Maestro also offers the ability to install an eye gaze system to access the device, which may be
necessary in the future due to the progressive nature of this disease.
A. General Features of Recommended SGD and Accessories
1. Input Features/Selection Technique
The patient will use an indirect selection technique via the joy stick on the wheelchair.
2. Message Characteristics/Features
a. The patient will use the DynaVox Compass 2.0 software. This software is comprised mainly of
symbols, but still has a text option to allow the patient to communicate novel thoughts.
b. The DynaVox Compass 2.0 software has the ability to store common messages that the patient
uses.
c. This device will allow the patients vocabulary, speaking rate and intelligibility to be greatly
enhanced through the use of word prediction functions and page setup on the device.
3. Output Features
The device will use a speech output in order for the patient to communicate in a variety of
contexts. The speech output does not require the listener to be directly in front of the user. This
device has a substantial battery life to allow the user to communicate throughout the day.
B. Recommended Medicare Device and Accessory Codes
The recommended device is the DynaVox Maestro. This device falls under the Medicare e-code
E2510. The mounting accessory falls under Medicare e-code E2512.
C. Description of equipment and procedures used during any demonstrations of the
recommended SGD and any other SGDs and accessories.
This device is recommended for the patient because they have physically used the device with a
positive outcome over three therapy sessions. The patient successfully communicated using this
device during the trial period.
D. SGD and accessories recommended
The individuals ability to achieve his/her functional communication goals requires the
acquisition and use of the DynaVox Maestro, the ConnectIt Mounting System Model #501792,
and the Corpus 3G Armrest Side Support. The mounting system will mount the device to the
wheelchair. Model #501792 was chosen because it is designed to mount the DynaVox Maestro
to tilt in space wheelchairs, which is what the patient currently uses. The Corpus 3G Armrest
Side Support and strap is recommended to eliminate the difficulty the patient is exhibiting with
keeping her arm on the joystick. This device represents the clinically most appropriate device for

Tammy Doe. This device and the recommended accessories will enable the patient to effectively
communicate wants and needs. The patient will be able to use the joy stick to directly select the
message she intends to communicate. The wheelchair mount will allow the device to be at eye
level where the patient can easily view the screen. The armrest support will allow the patients
hand to remain on the joystick without falling off to enable her to communicate at all times. This
will allow the patient to meet the functional communication goals set in place.
E. Patient/family support of SGD
The family is adamant about getting the patient a SGD to improve communication abilities. They
are advocating the recommendation of the DynaVox Maestro and support the equipment and its
use for daily communication.
F. Physician involvement statement
This report was forwarded to the treating physician, Debbie Houser M.D., on 11/16/2014 so that
she can write a prescription of the recommended SGD and accessories.
VI. Treatment Plan
The functional communication goals listed previously will be addressed in Speech Language
Therapy sessions one time a week for six weeks and will include training the patient and
caregivers on use of device and accessories. The therapy plan will include training of how to
mount the device, where icons are located within the device, what icons mean, how to work all
features of device (i.e, turn on and off, charging, etc), and how to use accessories. The therapy
sessions will be individual sessions. The patient and caregiver will also be trained as to who to
contact in case of trouble with the device. The functional goals will be achieved at the end of the
six week period. The projected frequency of reassessment will begin at 6 month intervals. Follow
ups will be done quarterly to see if the patients status or capabilities have changed at all.
VII. Functional Benefit of Upgrade
This section is not applicable to this patient.
VIII. SLP Assurance of Financial Independence and Signature
SLP: Stephanie L. Fowler
ASHA Certification#: 12000
State License #: PA10000
The Speech Language Pathologist performing this evaluation is not an employee of and does not
have a financial relationship with the supplier of any SGD.