Patient's Insurance Provider Does Not Consider Communication An Essential Activity Of Daily Living

Today I evaluated a gentleman who is 8 months post stroke and with persistent aphasia. Despite his understanding of language, and prior speech and language therapy elsewhere, his speech remains severely impaired, limiting his ability to communicate with his spouse or others in his day to day life. My goal today was to evaluate his ability to benefit from and use a speech generating device (SGD). A speech generating device typically uses some combination of pictures and words and has voice output in a naturalistic voice serving as a substitute for the patient's own voice. SGD's are speech aids that provide individuals with severe speech impairment the ability to meet their functional speaking needs. Today's evaluation results indicate that the patient has the interest, ability, and desire to benefit from obtaining and training in use of an SGD. The patient and his wife were nearly in tears as I shared my findings and recommendations with them.

As many insurance plans have a specific contractual exclusion of communication aids, with his being no exception,  I am  now gearing up for a fight with his insurance provider.

His specific provider, who for the moment shall remain anonymous, states rather clearly in their policy guidelines: the DME ( durable medical equipment) benefit "covers medical or surgical equipment for treatment of disease or injury, or to enable the person to perform essential activities of daily living related to the patient's health and hygiene." The patient's insurance provider does not consider communication to be a bodily function, and although considered an activity of daily living, it is said not to be related to the patient's health and hygiene.

So, in other words, a bed, wheelchair, or commode will be provided for, but, a communication device that meets a human beings most essential need  may be denied, as it is not considered an essential medical device.

Nearly everything we do in life depends on our ability to successfully communicate. That means hearing and speaking to others. How and why, therefore, I wonder, did it happen that meeting the needs of persons with communication impairments has been relegated some secondary place in our health care payment system?

This Too Is Good...

A friend sent me an uplifting message today taken from the Joyful Springer:

"We live in a physical world, and it’s easy to get so caught up in it that we forget that it is just a tiny fraction of reality.  True reality, the reality that encompasses everything, is an unseen one, an intelligence that connects all things.

Joyful Springers are alert to the mystical.  When life feels overwhelming or difficult, they remind themselves that under the physical circumstances is spiritual meaning that can lead them through the tough times to better ones.
Just because you can’t see it doesn’t mean it isn’t real.  The power that created worlds flows through you and around you.  When you’re aware of it, you will find far more joy and beauty in your life."

I try to always honor the spirit of the individuals I work with despite the emphasis on the physical symptoms. With true reciprocity these days, my patients have honored my spirit with kind words of support. At times in my life when I have felt burdened by difficulty, I have uttered the following affirmation:

This too is good, this too is God, and I demand to see the blessing in it...

Whatever any of us may be struggling with in our lives, I hope we can find comfort in a belief that we are always guided to right thought and action if we quiet the chatter in our own mind and listen.

A Simple Communication Board Can Help Following Aphasia

This past Saturday I visited my mother who was on day 40 of an unexpected and tumultuous acute care hospital stay. When I last saw her, she was less than 24 hours post stroke, and In the nine days since my return she had regained near normal function of her right arm and leg. While rapid recovery of motor function gives reason to be happy, her persistent expressive aphasia ( aphasia is difficulty with speaking or understanding language) has created frustration for her and for us as she attempts to communicate with family and hospital personnel. And, despite a **Joint Commission standard that states that a patient’s communication needs must be met, in the 9 days post stroke, no speech therapy intervention had been offered which might have helped to establish my mother’s communication abilities and decisional capacity. (The latter being especially relevant as we had scheduled a meeting to clarify my mother’s preferences regarding continued care. )
On Saturday, I introduced my mother to a simple communication board containing words and pictures. Adding to that, I had written down some personal information, including family member’s names. Quickly I was able to validate my family’s observation that her understanding of language was quite good, and despite the limitations of the available vocabulary, my mother quickly accessed the communication board , which was now secured to her hospital bed . Although communication with my mother is now a combination of pictionary, charades and twenty questions, communicate we have. We have clarified Advance Directives, answered my mother’s questions about the long hospital stay, and provided her an immediate way to request basic needs.
Two days ago, my mother was transferred to a rehabilitation facility. A new setting, unfamiliar people, and my mother’s limited ability to speak, has created a renewed anxiety in me. I have already had to clarify her first name which was listed in error on some records, facilitated her ability to respond to a “memory test”, a facility requirement, and a nearly impossible task for someone with aphasia, and we have waited, together, for a response to her call light. As I prepare to leave for a return home, I wonder and worry if her unpredictable and limited speech will serve her when I am not at the bedside to interpret.
The inability to effectively communicate occurs for many hospitalized patients, including those on ventilators, those with tracheostomy, and those with progressive loss of speech from neurogenic conditions such as ALS. If you are a family member of such a patient, and the patient has not yet been evaluated by a speech language pathologist, demand it from their physician. Of course, my recognition of the power and importance of communication has been the driving passion for what I have done professionally for the last 30 years, yet, there is still no preparation, it seems for the reality of seeing a family member’s vulnerability due to loss of speech.

** The Joint Commission is the accrediting agency for hospitals and other health care settings and annually establishes policies to guide standards of care including patient safety, and includes a requirement for meeting a patient’s communication needs. Please visit their website to learn more:http://www.jointcommission.org/

Aphasia Is Now An Unwelcome Visitor To My Life

On February 2, my mother suffered a stroke. (cerebral vascular accident/CVA). This came on day 27 of a long, protracted, and unexpected hospitalization. Her problem list was already rather complicated, and when I spent the week with her prior to the CVA, I was saddened and struck by how frail and weak she had become. The result of surgery, numerous medical procedures and immobility.
The stroke occurred one week ago on Thursday evening, and by Saturday, she had begun to have return of motor function on her right side, but she still could not speak. I returned to my home in Florida , and despite the celebratory mood of my family, I feared the worse, and that was that speech and language would be remain impaired.
Presently, my mother has expressive aphasia, which means she seems to understand language but is unable to speak. The young medical residents's suggestion that "maybe she could write," reminded me of how little doctors learn in medical school about language disorders from stroke or other neurogenic conditions. Because we communicate through many language modalities, speaking, writing, reading, it is frequently the case that when spoken language is impaired, written language is similarly impaired.
Prior to the stroke, I phoned my mom daily, asking how she was feeling, re-assuring her that she was getting better, and optimistically ( if not cautiously)  talking about a plan for discharge. Now, the silence on the other end of the phone, except for the very slightest vocalization, creates a void in my experience and a heaviness in my chest.
If  you believe as I do that the ability to speak and communicate is one of our greatest human gifts, than aphasia  is certainly a cruel thief.
More than 100,000 people acquire aphasia each year, most from stroke. To better understand aphasia  and  to and learn how you might help someone who has had a recent stroke, please visit: www.aphasia.org