PREAMBLE The Blind Rehabilitation service (BRS) established these Preferred Practice Patterns to enhance the quality of Blind Rehabilitation Center (BRC) programs. These statements were developed as a guide for blind rehabilitation specialists and as an educational tool for professionals, members of the general public, consumers, and administrators. In developing these statements, BRS intends to improve the information available to assist in providing better services in health care, education, and other settings in which blind rehabilitation services are offered. For each procedure, the Preferred Practice Patterns specify the professional who performs the procedure, expected outcomes, clinical indications for performing the procedure, clinical processes, setting and equipment specifications, safety and health precautions, and documentation aspects. It should be understood, however, that adherence to these Preferred Practice Patterns does not guarantee a desired outcome. In publishing these statements, BRS does not intend to exclude members of other professions or related fields who may render, in common practice areas, services for which they are competent by virtue of their respective disciplines. The Preferred Practice Patterns are the product of extensive peer review by BRS members. They have been circulated for comment by segments of the profession. In clinical areas of controversy, working groups were formed to reach consensus on accepted practice patterns. As a result, the practice patterns represent the consensus of the professions, having considered available scientific evidence, existing BRS and related policies, current practice patterns, expert opinions, and the collective judgment and experience of practitioners in the field. Requirements of federal and state governments and accrediting and regulatory agencies have also been considered. The Preferred Practice Patterns provide an informational basis to assist in enhancing veteran/veteran care. They are sufficiently definitive to guide practitioners in decision making for appropriate clinical outcomes. They further provide a focus for professional preparation, continuing education, and research activities. The Preferred Practice Patterns are neither a measurement of acceptable conduct nor a set of aspirational principles. Rather, they reflect the normally anticipated professional response to a particular set of circumstances. There may be legitimate reasons for departing from the practice patterns. The ultimate judgment regarding the appropriateness of any given procedure is made by the blind rehabilitation specialist in light of individual circumstances. Practitioners, however, should be aware of the Preferred Practice Patterns, carefully considering the justifications for alternative practices. I urrent practice based on the best available knowledge. Because blind rehabilitation is dynamic and continually developing, advances are expected to change current practice patterns. As new clinical, scientific, and technological developments take place, these statements will be updated to reflect those changes. GUIDING PRINCIPLES The following guiding principles formed the basis of the Preferred Practice Patterns. The practice patterns - 1. Keep paramount the welfare of veterans served in all practice decisions and actions. 2. Identify the professionals within the discipline who may perform any given procedure. 3. Address the clinical indications for performing any given procedure. 4. Define appropriate environmental factors related to procedures (e.g., setting, equipment, and materials). 5. Address demographic factors (e.g., age; development; education; occupation; and cultural, ethnic, linguistic, and social factors). 6. Consider risk as it relates to the health, safety, and welfare of veterans and practitioners and severity of blindness. 7. Consider outcomes of training as it relates to the enhancement of the quality of life. 8. Consider interdisciplinary approaches to service delivery. 9. Recognize the dignity of individuals and consider veteran rights, expectations, needs, and preferences. 10. Recognize the importance of documentation. 11. Recognize a variety of appropriate service delivery models and procedures (e.g., collaborative consultation, use of support personnel, and new and advanced technologies). 12. Have been developed as guidelines for blind rehabilitation service providers not mandates. II TABLE OF CONTENTS Preamble I Guiding Principle II Table of Contents III-IV 1.0 Computer Training 1 1.1 Computer Assessment 1 1.2 Computer Access Training 3 1.3 Assessing Request for Augmentative Device 4 2.0 Living Skills 6 2.1 Living Skills Assessment 6 2.2 Living Skills Instruction 7 2.3 Living Skills – Independent Living Program 9 3.0 Visual Skills 12 3.1 Visual Skills: Functional Visual Evaluation 12 3.2 Visual Skill Program Planning 13 3.3 Visual Skill Training 14 4.0 Manual Skills 16 4.1 Manual Skills Assessment 16 4.2 Manual Skills Program Planning 17 4.3 Manual Skills Instruction 19 5.0 Orientation and Mobility 21 5.1 Orientation and Mobility Assessment 21 5.2 Orientation and Mobility Program Planning 23 5.3 Orientation and Mobility Instruction 24 6.0 Clinical Review Process 26 7.0 Continuing Education 27 8.0 Family Education 28 9.0 Health Status Assessment 30 10.0 Recreation/Leisure Time Skills Development 32 11.0 Prosthetics 33 11.1 Prosthetics Issuance 33 11.2 Prosthetic Adaptive Device Assessment 34 III 12.0 Blind Rehabilitation Resource Class 36 13.0 Team Coordination 38 14.0 Glossary of Terms 40 15.0 References 45 IV 1.0 1.0 COMPUTER TRAINING (If applicable) 1.1 COMPUTER ASSESSMENT 1.1.1 DEFINITION OF PROCEDURE Assessments are conducted to determine a veteran’s appropriateness for computer access training. Assessments will identify the veteran’s needs, preferences, strengths, weaknesses and abilities. Assessments will be used to develop an individualized training program to assist the veteran in overcoming the handicap of blindness and meet expressed goals. 1.1.2 WHO PERFORMS BRC staff members, who have demonstrated the required competencies, are authorized to conduct Computer Access assessments to the extent to which they have been formally trained. 1.1.3 EXPECTED OUTCOMES The Specialist will have completed an assessment of the prerequisite skills that are needed to begin training (i.e. typing). The Specialist will have identified the access equipment that will best meet the veteran’s needs. The Specialist will have identified other prosthetic aids that will be incorporated into the training program (i.e. magnifiers, prescription lenses, etc.). The assessment will result in a description of the veteran’s strengths, weaknesses, needs, preferences and desired outcomes as they relate to computer access training. The Specialist will develop an individualized treatment plan. 1.1.4 CLINICAL INDICATION FOR PROCEDURE All veterans admitted to a BRC for computer access training will have their level of computer knowledge and computer access needs assessed. Veterans admitted to a BRC for a comprehensive training program of adjustment to sight loss may have their level of computer knowledge and computer access needs assessed if the veteran’s goals so indicate. 1.1.5 CLINICAL PROCESS BRC staff assessments are conducted prior to the start of training. Assessments utilize a variety of subjective and objective tools to identify a veteran’s training needs. The evaluation process should include consideration of ergonomics, comfort, health status, hearing impairment, physical limitations, special learning needs, patient preferences and performance level when determining efficiency and effectiveness. The evaluation process should include documentation of training needs, the appropriate learning environment, and/or any training modifications necessary for the veteran to successfully achieve his/her stated goals. 1.1.6 SETTING AND EQUIPMENT SPECIFICATIONS The clinical environment is within the Blind Rehabilitation Center. Assessments are conducted on equipment that meets VA and industry standards. The equipment may include large print, speech, Braille, optical and non-optical aids. 1.1.7 DOCUMENTATION Documentation contains pertinent background information, assessment results, veteran goals, and specific recommendations regarding training or referral. When instruction is recommended, information should be provided concerning the frequency, estimated duration, type of service required, and expected outcomes. Documentation illustrates that the BRC consistently applies policies and procedures. Documentation demonstrates that VIST and BROS have collaborated with the BRC on the development of patient treatment plans. 1.1.8 POLICY AND RELATED REFERENCES Refer to reference page 1.2 COMPUTER ACCESS TRAINING 1.2.1 DEFINITION OF PROCEDURE Computer Access Training is defined as the formal procedures used to provide instruction on the various computer access devices and related equipment as deemed appropriate by the Computer Access Assessment. 1.2.2 WHO PERFORMS BRC staff members, who have demonstrated the required competencies, are authorized to provide computer access instruction and training to the extent to which they have been formally trained to provide such services. 1.2.3 EXPECTED OUTCOMES Veterans must demonstrate the ability to independently operate the computer hardware and software to achieve their stated goal(s). 1.2.4 CLINICAL INDICATION FOR PROCEDURE Instruction is provided to veterans who meet the criteria for eligibility and issuance and have successfully completed the computer assessment. 1.2.5 CLINICAL PROCESS Both formal and informal assessment results are analyzed. Both formal and informal instructional programs are utilized. Training should be designed and paced to meet the specific goals, objectives and capabilities of each veteran. Blinded veterans will be given a reasonable opportunity to successfully complete any necessary training. The veteran meets issuance criteria as outlined in the VHA Prosthetic Clinical Management Program Clinical Practice Recommendations. 1.2.6 SETTING AND EQUIPMENT SPECIFICATIONS Clinical environment within the Blind Rehabilitation Centers and Clinics provides the setting and equipment. Training and assessments are conducted on equipment that meets VA and industry standards. The equipment includes large print, speech, Braille, optical and non-optical aids. 1.2.7 DOCUMENTATION Appropriate documentation will be maintained in the medical record that clearly identifies the veteran’s stated goals; the evaluation and training provided; and the veteran’s functional ability to use the prescribed equipment and software effectively to meet the stated goals. 1.2.8 POLICIES AND RELATED REFERENCES Refer to reference page. 1.3 ASSESSING REQUEST FOR AUGMENTATIVE DEVICE 1.3.1 DEFINITION OF PROCEDURE Veterans are often required to perform tasks, which cannot be accomplished without some modifications to existing equipment. This Preferred Practice Pattern indicates the formal assessment procedures required to determine appropriateness for modifications to standardized off-the-shelf equipment that will allow the visually impaired user to function Independently. 1.3.2 WHO PERFORMS Blind Rehabilitation Specialists, Supervisors, and Medical Personnel, Research Personnel, Engineers, Technology Transfer Specialists. 1.3.3 EXPECTED OUTCOMES Identify the need for an augmentative device. Identify type of adaptation necessary. Identify and review available resources. Develop recommendations for fabrication or adaptation of commercial products. Develop a treatment plan. 1.3.4 CLINICAL INDICATION FOR PROCEDURE Requests from eligible veterans are considered for appropriateness. 1.3.5 CLINICAL PROCESS A review of the veteran’s medical records will be completed. Self-assessment by the veteran is compared with that of the instructor. Both formal and informal assessment results are analyzed. Review available resources and identify interested vendors. Interview appropriate individuals pertinent to the request to help define the problem. 1.3.6 SETTING AND EQUIPMENT SPECIFICATIONS Clinical, natural environments, or a model shop will be used during the evaluation. Assessments are conducted using equipment that meets safe and accepted standards. 1.3.7 DOCUMENTATION Contains a statement of background information, assessment results, any special considerations, recommendations, and a developer. 1.3.8 POLICY AND RELATED REFERENCE Refer to reference page 2.0 LIVING SKILLS 2.1 LIVING SKILLS ASSESSMENT 2.1.1. DEFINITION OF PROCEDURE Formal assessment procedures, characterized by observation, interview, and report review, provide Living Skills instructors with information that enables the development of an individualized treatment program for each visually impaired veteran entering the Living Skills program. 2.1.2 PROFESSIONALS WHO PERFORM THE PROCEDURES BRC staff members, who have demonstrated the required competencies, are authorized to conduct Living Skills assessments to the extent to which they have been formally trained. 2.1.3 EXPECTED OUTCOMES The assessment will result in a description of the veteran’s strengths, weaknesses, needs, preferences and desired outcomes as they relate to living skills training. Assessments will result in recommendations for instruction or referrals for other examinations or services. 2.1.4 CLINICAL INDICATION FOR PROCEDURE All veterans admitted to a BRC for a comprehensive training program of adjustment to sight loss will have their level of functioning in Living Skills assessed. 2.1.5 CLINICAL PROCESS BRC staff assessments will utilize a variety of subjective and objective tools to identify a veteran’s training needs. Assessments need to address a person’s strengths, weaknesses, needs, preferences and desired outcomes. Assessments need to include information relating to the veteran’s lifestyle, age, culture, medical condition, cognitive ability, previous training and future plans. Individuals are placed in clinical as well as realistic environments to assess daily living and communication skills. The results of assessments are analyzed and shared with the veteran when formulating an individualized treatment program. 2.1.6 SETTING/EQUIPMENT SPECIFICATIONS All Living Skills assessments are conducted in the most practical setting with consideration for physical, acoustic, and visual characteristics. Other Aids for the Blind (e.g. canes, low-vision aids, etc.) are included in systematic ways in order to assess the contributions they make to the skills being assessed. Equipment utilized in Living Skills assessments will meet professional standards for safety and function. 2.1.7 DOCUMENTATION Documentation contains pertinent background information, assessment results, veteran and instructor goals, specific recommendations, and anticipated living situation. When instruction is recommended, information should be provided concerning the frequency, estimated duration, type of service required, and expected outcomes. Documentation will be maintained in the medical center record and accomplished according to VHA, BRS and local VA policy. Medical records will be consistent with local requirements, as well as JCAHO and CARF regulatory standards. Documentation illustrates that BRC instructors consistently apply policies and procedures. 2.1.8 PROFESSIONAL POLICY AND RELATED REFERENCES Refer to reference page 2.2 LIVING SKILLS INSTRUCTION 2.2.1 DEFINITION OF PROCEDURE Instruction assists veterans in the attainment of not only a maximum level of safety and independence in living skills but also improved levels of confidence, self-esteem, and quality of life. 2.2.2 PROFESSIONALS WHO PERFORM PROCEDURES BRC staff members, who have demonstrated the required competencies, are authorized to provide Living Skills instruction and training to the extent to which they have been formally trained to provide such services. 2.2.3 EXPECTED OUTCOMES Instruction provides techniques for safe and efficient completion of living skills tasks. Instruction provides the opportunity for the enhancement of self-confidence and self-esteem. Instruction supplies a knowledge base of resources and adaptive aids and devices. 2.2.4 CLINICAL INDICATION FOR PROCEDURE Individualized instruction is based on the results of the Living Skills assessments. 2.2.5 CLINICAL PROCESS Living Skills instruction is a part of the inter-disciplinary rehabilitation process. Short and long term goals and specific objectives are determined from assessments and represent the framework for instruction. They are reviewed periodically to determine appropriateness. Instruction will cover the effective use of adaptive techniques or equipment in activities of daily living and communications. Performance is determined by a comparison of the initial assessment results to the veteran’s level of skill enhancement at discharge by the inter-disciplinary team. Instruction is outlined in the curriculum for each living skill area. 2.2.6 SETTING/EQUIPMENT SEPCIFICATIONS Communications instruction is conducted in classrooms. ADL instruction is conducted in a training apartment or the most realistic setting. All Living Skills instruction is conducted with consideration for physical, acoustic and visual characteristics of the environment. Other Aids for the Blind (e.g. canes, low-vision aids, etc.) are included in systematic ways in order to assess the contributions they make to the skills being assessed. 2.2.7 DOCUMENTATION The documentation of patient assessments, treatment plans, progress notes and discharge summaries will be maintained in the medical center record and accomplished according to VHA, BRS and local VA policy. Medical records will be consistent with local requirements, as well as JCAHO and CARF regulatory standards. Documentation illustrates that BRC instructors consistently apply policies and procedures. 2.2.8 POLICY AND RELATED REFERENCES Refer to reference page 2.3 INDEPENDENT LIVING PROGRAM (If applicable) 2.3.1 DEFINITION OF PROCEDURE Participation in the Independent Living Program enables the veteran to engage in a variety of everyday living activities that will most likely be encountered upon discharge and provides the inter-disciplinary team with an evaluation of the veteran’s level of functioning prior to discharge. 2.3.2 PROVIDERS BRS Instructors BRS Supervisors Other BRS professional staff when appropriate 2.3.3 EXPECTED OUTCOME The ILP experience provides the opportunity for the enhancement of self-confidence and self-esteem. The ILP experience enables the veteran to incorporate adaptive aids and techniques acquired during training into realistic, everyday situations. The ILP experience provides a variety of opportunities for problem-solving, personal and household management, and use of leisure time. Evaluation will identify and describe each veteran’s current skill levels. Evaluation will result in recommendations for further training. 2.3.4 CLINICAL INDICATION FOR PROCEDURE All veterans are evaluated by members of the inter-disciplinary team throughout the training program and are provided with a variety of experiences that are designed to meet their needs for independent living. 2.3.5 CLINICAL PROCESS The ILP is part of the inter-disciplinary rehabilitation process. The inter-disciplinary team working with each veteran will determine the intensity and variety of experiences each veteran should be given to the ILP. The ILP experiences are reviewed by the Team Coordinator and appropriate feedback is given to the veteran participating in the program. Experiences will cover the effective use of adaptive techniques and equipment in everyday activities that include personal and household management, travel, communications, utilization of resources, and involvement in leisure programs. The Team Coordinator and the veteran will evaluate the ILP experience. Any areas needing additional training will be discussed and scheduled into the veteran’s program. The guidelines for participation in this program are outlined in the curriculum for the ILP. In case of health or safety concerns, the Team Coordinator will meet with the veteran to intervene as soon as necessary. 2.3.6 SETTING/EQUIPMENT SPECIFICATONS The ILP experiences will be provided in an environment, whereby the veteran will demonstrate the ability to independently perform tasks of daily living. For some veterans, an apartment setting will be furnished so that the veteran can be self-sufficient for an established period of time. For other veterans, ILP activities will be conducted in classrooms or the most practical setting available. The equipment used during the ILP will be furnished by the BRC. 2.3.7 DOCUMENTATION Documentation contains pertinent background information, evaluation results, specific recommendations, and anticipated living situation. Recommendations may address the need for further training, evaluation, follow-up, or referral. When further instruction is recommended, information should be provided concerning the frequency, estimated duration, and type of instruction required. Documentation will be maintained in the medical center record and accomplished according to VHA, BRS and local VA policy. Medical records will be consistent with local requirements, as well as JCAHO and CARF regulatory standards. Documentation shows that BRC instructors consistently apply policies and procedures. 2.3.8 POLICY/RELATED REFERENCE Refer to reference page. 3.0 VISUAL SKILLS 3.1 VISUAL SKILLS: FUNCTIONAL VISION EVALUATION 3.1.1 DEFINITION OF PROCEDURE The procedure to determine the visual potential and abilities of the veteran. 3.1.2 PROFESSIONAL WHO PERFORMS PROCEDURE BRC staff members, who have demonstrated the required competencies, are authorized to conduct Visual Skills assessments to the extent to which they have been formally trained. 3.1.3 EXPECTED OUTCOMES The assessment will result in a description of the veteran’s strengths, weaknesses, needs, preferences and desired outcomes as they relate to low vision training. Veterans will be given information/counseling regarding assessment findings. A treatment plan and visual profile will be formulated. 3.1.4 CLINICAL INDICATION FOR PROCEDURE All veterans admitted to a BRC for a comprehensive training program of adjustment to sight loss will have their level of visual functioning assessed. 3.1.5 CLINICAL PROCESS The clinical process will include completion of the following items: intake interview, visual history, distance and near acuities, visual fields, functional evaluations, color testing, optometric and ophthalmological exams, veterans self assessment. 3.1.6 SETTING/EQUIPMENT SPECIFICATIONS Visual assessments will be conducted in a room/area containing specialized equipment and tests. Efforts will be made to assure that all equipment used will not be sub-standard. 3.1.7 DOCUMENTATION Documentation will be maintained in the medical center record and accomplished according to VHA, BRS and local VA policy. Medical records will be consistent with local requirements, as well as JCAHO and CARF regulatory standards. Documentation illustrates that BRC instructors consistently apply policies and procedures. Documentation contains pertinent background information, assessment results, veteran and instructor goals, and specific recommendations. Recommendations may address the need for further assessment, follow- up, or referral. When instruction is recommended, information should be provided concerning the frequency, estimated duration, type of service required, and expected outcomes. 3.1.8 POLICIES AND RELATED REFERENCES Refer to reference page. 3.2 VISUAL SKILLS PROGRAM PLANNING 3.2.1 DEFINITION OF PROCEDURE Visual Skills Program Planning is the process of converting data from the ophthalmologic, optometric, and visual skills instructor assessments, along with the veteran’s self assessment and identified goals into an individualized Visual Skills Training Program. 3.2.2 PROFESSIONALS WHO PERFORM PROCEDURE BRC staff members, who have demonstrated the required Visual Skills competencies, are authorized to plan a Visual Skills program. 3.2.3 EXPECTED OUTCOME An individualized Visual Skills Training Program will be developed. 3.2.4 CLINICAL INDICATION FOR PROCEDURE All veterans admitted to a BRC for a comprehensive training program of adjustment to sight loss receive vision rehabilitation as indicated by visual assessments. 3.2.5 CLINICAL PROCESS Assemble assessment results. Interact with veteran to conduct the needed assessment. Develop a Visual Skills training program that is consistent with established guidelines for Visual Skills. 3.2.6 SETTING/EQUIPMENT SPECIFICATIONS Not applicable. 3.2.7 DOCUMENTATION A written low vision training plan will be formulated. The treatment plan needs to recognize the veteran’s expressed goals and be individualized to meet the veteran’s needs relevant to lifestyle, age, level of capability, and future plans. Specific measurable objectives must be identified along with the strategies that will be used to achieve them. 3.2.8 POLICY AND RELATED REFERENCES Refer to reference page. 3.3 VISUAL SKILLS TRAINING 3.3.1 DEFINITION OF PROCEDURE The training procedure designed to improve near vision, intermediate vision, and distance vision. 3.3.2 PROFESSIONALS WHO PERFORM PROCEDURE BRC staff members, who have demonstrated the required competencies, are authorized to provide Visual Skills training to the extent to which they have been formally trained to provide such services. 3.3.3 EXPECTED OUTCOMES The following outcomes will be anticipated: -reading normal size print -knowledge of low vision devices -expertise with low vision devices issued -reading of signs and other distance viewing -increased independence -knowledge of personal eye condition -visual improvement for application to mechanical tasks - knowledge of contrast background to enhance performance -improvement of personal communication skills (handwriting) -knowledge of appropriate illumination -improvement of eccentric viewing skills when applicable 3.3.4 CLINICAL INDICATION FOR PROCEDURE All veterans with reduced visual functioning will be provided training as recommended by the interdisciplinary team. 3.3.5 CLINICAL PROCESS The clinical process will include: -reading training -eccentric viewing training -hand and pocket magnifier training -monocular training -CCTV training -use of illumination devices -eye tracking devices -handwriting exercises Instructors continually monitor and adjust the treatment plan in response to demonstrated strengths, weaknesses, changing needs, and expected outcomes in order to ensure that goals remain achievable and meaningful to the person receiving services. 3.3.6 SETTING/EQUIPMENT SPECIFICATIONS Instruction areas include clinical areas within the BRC. Most equipment will consist of low vision optical devices, trial frames with sample eyeglass prescriptions, electronic visual aids, lamps, reading stands, and other non-optical devices. 3.3.7 DOCUMENTATION Documentation will be maintained in the medical center record and accomplished according to VHA, BRS and local VA policy. Medical records will be consistent with local requirements, as well as JCAHO and CARF regulatory standards. Documentation illustrates that BRC instructors consistently apply policies and procedures. 3.3.8 POLICIES AND RELATED REFERENCES Refer to reference page. 4.0 MANUAL SKILLS 4.1 MANUAL SKILLS ASSESSMENT 4.1.1 DEFINITION Objective (instrument based) and Subjective (program based) Functional Assessments are conducted in order to determine the strengths and weaknesses in the veteran’s ability to gather and utilize the information made available to them from a wide variety of senses and stimuli. 4.1.2 PROFESSIONAL WHO PERFORM PROCEDURE BRC staff members, who have demonstrated the required competencies, are authorized to conduct Manual Skills assessments to the extent to which they have been formally trained. 4.1.3 EXPECTED OUTCOME The Objective Assessment will result in a clinical assessment that describes the veteran’s perceptual abilities as they existed at the time of the assessment. The Subjective Assessment will provide insight into the veteran’s developing ability to utilize information from his remaining senses. 4.1.4 CLINICAL INDICATION FOR PROCEDURE All veterans admitted to a BRC for a comprehensive training program in adjustment to sight loss will have their Manual Skills training needs assessed. 4.1.5 CLINICAL PROCESS BRC staff assessments are conducted prior to the start of training. Assessments utilize a variety of subjective and objective tools to identify a veteran’s training needs. The evaluation process should include consideration of ergonomics, comfort, health status, hearing impairment, physical limitations, special learning needs, patient preferences and performance level when determining efficiency and effectiveness. The evaluation process should include documentation of training needs, the appropriate learning environment, and/or any training modifications necessary for the veteran to successfully achieve his/her stated goals. 4.1.6 SETTING/EQUIPMENT SPECIFICATIONS The clinical environment is within the Blind Rehabilitation Center. Assessments are conducted on equipment that meets VA and industry standards. 4.1.7 DOCUMENTATION Documentation will be maintained in the medical center record and accomplished according to VHA, BRS and local VA policy. Medical records will be consistent with local requirements, as well as JCAHO and CARF regulatory standards. Documentation illustrates that BRC instructors consistently apply policies and procedures. Documentation contains pertinent background information, assessment results, veteran and instructor goals, and specific recommendations. When instruction is recommended, information should be provided concerning the frequency, estimated duration, type of service required, and expected outcomes. 4.1.8 POLICY/RELATED REFERENCES Refer to reference page. 4.2 MANUAL SKILLS PROGRAM PLANNING 4.2.1 DEFINITION OF PROCEDURE Manual Skills program planning is the process of converting data from the assessments (objective & subjective), the veteran’s goals, and the instructor’s knowledge of the resources available, into an individualized Manual Skills training program. 4.2.2 PROFESSONALS WHO PERFORM PROCEDURES BRC staff members, who have demonstrated the required Manual Skills competencies, are authorized to plan a Manual Skills program. 4.2.3 EXPECTED OUTCOME Development of an appropriate individualized training program with achievable goals. 4.2.4 CLINICAL INDICATION FOR PROCEDURE At the conclusion of the assessment process, an individualized training program will be developed for all veterans admitted to a BRC for a comprehensive training program in adjustment to sight loss. 4.2.5 CLINICAL PROCESS Assemble results of assessments. Interact with veteran to conduct a subjective needs assessment and determine his/her goals. Develop a Manual Skills training program that is consistent with the established professional guidelines for Manual Skills. Review the training program with the veteran and reach consensus. Modify the treatment plan, when indicated, in response to changing needs. 4.2.6 SETTING/EQUIPMENT SPECIFICATIONS Not applicable. 4.2.7 DOCUMENTATION A written training plan with achievable goals is formulated. 4.2.8 POLICY/RELATED REFERENCES Refer to reference page 4.3 MANUAL SKILLS INSTRUCTION 4.3.1 DEFINITION OF PROCEDURE Blinded veterans are guided through a series of activities, which are graduated in difficulty and designed to challenge their ability to gather information using their other senses. The veteran is then required to incorporate this information into the solution of complex problems. 4.3.2 PROFESSIONALS WHO PERFORM PROCEDURES BRC staff members, who have demonstrated the required competencies, are authorized to provide Manual Skills instruction and training to the extent to which they have been formally trained to provide such services. 4.3.3 EXPECTED OUTCOME At the conclusion of this training, blinded veterans will have enhanced their skills in all aspects of sensory awareness with an emphasis on adaptive and safety techniques. Skill training will have improved the blinded veteran’s organizational skills, tactual awareness, spatial awareness, memory sequencing, problem solving and self-confidence. 4.3.4 CLINICAL INDICATION FOR PROCEDURE Individualized instruction is based on the results of the Manual Skills assessments. 4.3.5 CLINICAL PROCESS Initially, instructors work with groups of 2-3 blinded veterans who complete a series of activities that have been designed to help develop the basic concepts of using tactual perception, dexterity, and bi-manual coordination as an alternative means of gathering information and problem solving. In the advanced area of instruction, blinded veterans learn about and routinely operate hand tools and power machinery as they construct a series of complex projects that have been designed to further develop and challenge their skill at gathering and utilizing non-visual information along with their other abilities. The instructor continually monitors progress and adjusts the training plan in response to the veteran’s changing needs. 4.3.6 SETTING/EQUIPMENT SPECIFICATONS Initial training and assessment requires a well-lighted room with tables and chairs where veterans can plan and assemble their projects. These activities may include: leatherworking, copper tooling and/or macramé. Advanced training and assessment requires an industrial arts setting. Facilities must be available for woodworking, home mechanics, and small engine repair. The area must be equipped with the full range of hand and power tools, as well as wood machinery including: tablesaw, bandsaw, lathe, drill press, radial arm saw, surfacer and jointer. The wood shop must have an appropriate dust collector system. Hearing and eye protection should be provided. 4.3.7 DOCUMENTATION Documentation will be maintained in the medical center record and accomplished according to VHA, BRS and local VA policy. Medical records will be consistent with local requirements, as well as JCAHO and CARF regulatory standards. Documentation illustrates that BRC instructors consistently apply policies and procedures. 4.3.8 POLICY/RELATED REFERENCES Refer to reference page 5.0 ORIENTATION AND MOBILITY 5.1 ORIENTATION AND MOBILITY ASSESSMENT 5.1.1 DEFINITION OF PROCEDURE Objective & subjective tools are utilized to identify a veteran’s orientation and mobility training needs in a variety of environments. 5.1.2 PROFESSIONAL WHO PERFORMS PROCEDURE BRC staff members, who have demonstrated the required competencies, are authorized to conduct orientation & mobility assessments to the extent to which they have been formally trained. 5.1.3 EXPECTED OUTCOMES The assessment will result in a description of the veteran’s strengths, weaknesses, needs, preferences and desired outcomes as they relate to orientation & mobility. 5.1.4 CLINICAL INDICATION FOR PROCEDURE All veterans admitted to a BRC for a comprehensive training program of adjustment to sight loss will have their Orientation & Mobility needs assessed. 5.1.5 CLINICAL PROCESS Each veteran will be exposed to a variety of assessments designed to include a variety of visual, tactual, and auditory stimuli. Formal and informal assessments are applied and documented as related to mobility skills such as but not limited to: -Obstacle detection -Detection of Drop-Offs -Line of Travel -Balance Formal and informal assessments are applied and documented as related to orientation skills such as but not limited to: -Memory Retention -Sensory Awareness -Geographic Directions During all stages of the assessment process, the blind rehabilitation specialist should be alert and sensitive to any personal or physical problem(s) indicating the need for immediate attention from other clinical staff. During the assessment process, the veteran’s perceived needs and individual goals for orientation and mobility will be established. 5.1.6 SETTING AND EQUIPMENT SPECIFICATIONS O&M assessments are conducted in a variety of appropriate environments such as but not limited to: -Indoor -Residential -Business -Night -Public Transit Systems -Other areas related to veteran’s home environment Canes, low vision aids, hearing aids, and other appropriate devices are included in systematic ways in order to assess the contribution they make to the skills being assessed. Individuals are placed in clinical as well as natural environments to assess their orientation and mobility needs. 5.1.7 DOCUMENTATION Documentation will be maintained in the medical center record and accomplished according to VHA, BRS and local VA policy. Medical records will be consistent with local requirements, as well as JCAHO and CARF regulatory standards. Documentation illustrates that BRC instructors consistently apply policies and procedures. Documentation contains pertinent background information, assessment results, veteran and instructor goals, and specific recommendations. Recommendations may address the need for further assessment, follow- up, or referral. When instruction is recommended, information should be provided concerning the frequency, estimated duration, type of service required, and expected outcomes. 5.2 PROGRAM PLANNING 5.2.1 DEFINITION OF PROCEDURE Program planning is the process of converting data from the clinical assessment, along with veteran input, into an individualized Orientation and Mobility training program. 5.2.2 PROFESSIONAL WHO PERFORMS PROCEDURE BRC staff members, who have demonstrated the required competencies, are authorized to plan an Orientation & Mobility program. 5.2.3 EXPECTED OUTCOMES The veteran’s program in Orientation & Mobility will be individualized and will include veteran goals. 5.2.4 CLINICAL INDICATION FOR PROCEDURE All veterans admitted to a BRC for a comprehensive training program of adjustment to sight loss receive orientation and mobility training as indicated by the assessment. 5.2.5 CLINICAL PROCESS The specialist will assemble the assessment results. The specialist will interact with the veteran to conduct a needs assessment. The specialist will develop an orientation and mobility training program that is consistent with established professional guidelines for orientation and mobility. The training plan will include the veteran’s goals and be shared with the veteran. 5.2.6 SETTING AND EQUIPMENT SPECIFICATIONS Not applicable 5.2.7 DOCUMENTATON A written orientation and mobility training plan is formulated. The treatment plan will recognize the veteran’s expressed goals and be individualized to meet the veteran’s needs relevant to lifestyle, age, level of capability, and future plans. Specific measurable objectives must be identified along with the strategies that will be used to achieve them. 5.3 ORIENTATION AND MOBILITY INSTRUCTION 5.3.1 DEFINITION OF PROCEDURE Orientation & Mobility instruction is the process whereby persons are trained to effectively use their remaining senses in combination with protective techniques and assistive devices that enable the individual to independently travel in a safe, efficient, and confident manner in both familiar and unfamiliar environments. 5.3.2 PROFESSIONAL WHO PERFORMS PROCEDURE BRC staff members, who have demonstrated the required competencies, are authorized to provide Orientation & Mobility instruction and training to the extent to which they have been formally trained to provide such services. 5.3.3 EXPECTED OUTCOMES O&M instruction will improve the veteran’s ability to identify, process, utilize environmental information, and apply appropriate protective techniques in order to travel as safely, independently, and efficiently as possible. The veteran will achieve a realistic appreciation of his capabilities and limitations as they relate to Orientation and Mobility. The veteran will demonstrate an increase in self-confidence and self-esteem. 5.3.4 CLINICAL INDICATION FOR PROCEDURE All veterans admitted to a BRC for a comprehensive training program of adjustment to sight loss receive orientation and mobility training as indicated by the assessments. 5.3.5 CLINICAL PROCESS Implement instruction program. Most instruction is addressed on a one to one basis and conducted in a sequential manner in order to establish a success pattern by moving from simple lessons to those that are more complex. Instructors continually monitor and adjust the treatment plan in response to demonstrated strengths, weaknesses, changing needs, and expected outcomes in order to ensure that goals remain achievable and meaningful to the person receiving services. Based on clinical observation, a determination is made by the instructor when the veteran has reached maximum potential. 5.3.6 SETTING AND EQUIPMENT SPECIFICATIONS Travel environments include but are not limited to: indoor, residential, light business, urban, rural, and shopping malls. Travel situations include: navigating inside restaurants and stores, crossing streets at controlled and uncontrolled intersections, locating landmarks, using public transportation, etc. Travel devices include: the long cane, support canes, telescopic aids, sunglasses, and alternative mobility devices such as walkers. 5.3.7 DOCUMENTATION Documentation will be maintained in the medical center record and accomplished according to VHA, BRS and local VA policy. Medical records will be consistent with local requirements, as well as JCAHO and CARF regulatory standards. Documentation illustrates that BRC instructors consistently apply policies and procedures. 6.0 CLINICAL REVIEW PROCESS 6.1.1 DEFINITION OF PROCEDURE Provide a vehicle for sharing of goals and assessments with the veteran and other members of the interdisciplinary team. To establish a unified goal and treatment program in order to achieve maximum results from the instruction. 6.1.2 PROFESSIONAL WHO PERFORM PROCEDURE All participating members of the veteran’s blind rehabilitation multi-disciplinary team. 6.1.3 EXPECTED OUTCOME The formulation and presentation of a formal plan that will encompass all aspects of the instruction program. This is accomplished through the presentation of verbal or written evaluations by all participating members of the team. This will encompass all aspects of instruction and establish a unified approach to address the attitudes required to adjust to sight loss. 6.1.4 CLINICAL INDICATION FOR PROCEDURE Clinical reviews are provided as part of the comprehensive rehabilitation process. They establish a baseline level with which to address the specific needs of the veteran in all aspects of his instruction within two weeks of entry to the program. 6.1.5 CLINICAL PROCESS The clinical review process for the veterans may include but not limited to: -Results of assessments in all skills areas -Sharing of pertinent information that may effect the veterans program (i.e. background, medical) -A reaffirmation of veteran’s goals/preferences -A reaffirmation of the instructor’s recommended goals for the veteran -The course to be followed to achieve these goals -Establishment of a tentative discharge date 6.1.6 SETTING/EQUIPMENT SEPCIFICATIONS The clinical review setting is conducive to veteran comfort, confidentiality, and uninterrupted privacy. 6.1.7 DOCUMENTATION Documentation includes a specific summary of the reports from all of the skill area and an overall summation, which includes a tentative discharge date. Documentation will demonstrate veteran’s concurrence of his/her proposed treatment plan. 6.1.8 POLICY AND RELATED REFERENCES Refer to reference page 7.0 CONTINUING EDUCATION 7.1.1 DEFINITION OF PROCEDURE Formal procedures to provide, on a recurring basis, updated information on methodologies, techniques, and new technology specific to blind rehabilitation and related fields for all professional staff within blind rehabilitation programs. 7.1.2 WHO PERFORMS Supervisors, Blind Rehabilitation Specialists, Psychologist, Research, Social Worker, Regional Consultants, Optometry and other experts within specific fields. 7.1.3 EXPECTED OUTCOMES Continuing education needs of the staff are defined. Available resources are identified and reviewed. A continuing education plan is developed. Employees gain new knowledge which has direct application to their position. Employees have a more defined method for keeping abreast of emerging developments and technology within the profession. 7.1.4 CLINICAL INDICATION FOR PROCEDURE Continuing Education courses are prepared and presented as deemed necessary by a continuing education committee, supervisors, or staff. 7.1.5 CLINICAL PROCESS Informal and formal assessments are conducted by the continuing education committee or supervisors. Formal presentations are provided by appropriate professionals. 7.1.6 SETTING AND EQUIPMENT SPECIFICATONS Clinical environment within the Blind Rehabilitation Center, indoor environments outside the Blind Rehabilitation Center and/or natural environments will be used during the assessments and education as deemed appropriate. Any equipment utilized will meet safe and accepted standards. 7.1.7 DOCUMENTATION Appropriate documentation is maintained in employee’s personnel file regarding completion of educational programs. 7.1.8 POLICY AND RELATED PROCEDURES Refer to reference page 8.0 FAMILY EDUCATION 8.1.1 DEFINITION OF PROCEDURE Providing information and guidance to the family on blindness and the veteran’s performance and functional abilities as related to his/her visual loss. 8.1.2 PROFESSIONAL WHO PERFORMS PROCEDURE All members of the blind rehabilitation multidisciplinary team 8.1.3 EXPECTED OUTCOME Professionals assist family members and/or significant others to adjust to living with the veteran’s sight loss. Discussions with the family will include the veteran’s: attitude adjustment, capabilities, limitations, functional skills, and education regarding blindness. 8.1.4 CLINICAL INDICATION FOR PROCEDURE Family counseling services are encouraged and provided as part of the comprehensive blind rehabilitation programs. 8.1.5 CLINICAL PROCESS Educational experiences and counseling services for family program participants may include: -assessment of counseling needs -provide information and guidance on related aspects of the rehabilitation process -education in the use of adaptive equipment and techniques needed to modify the lifestyle of the veteran -development of a support network to convey information on services available to the blind and visually impaired community -adequate counseling about the veteran’s adjustment to sight loss 8.1.6 SETTING/EQUIPMENT SPECIFICATIONS Counseling is conducted in a setting conducive to veteran/veteran and family comfort, confidentiality, and privacy. 8.1.7 DOCUMENTATION Documentation includes a statement that the participant was actively involved in the family education program. 8.1.8 POLICY/RELATED REFERENCES Refer to reference page 9.0 HEALTH STATUS ASSESSMENT 9.1.1 DEFINITION OF PROCEDURE A systematic collection and analysis of specific data relevant to each veteran, which has been gathered by direct and indirect contact. This will include observation, interview, past medical chart review, and talking with family members and other significant others as deemed necessary. This assessment begins when the health care team member first meets the veteran and includes consideration and prioritization of physical, psychosocial, self-care, educational, environmental, and discharge planning needs. Documentation and course of action are continuously defined and redefined throughout the veteran contact with the Blind Rehabilitation Center. 9.1.2 PROFESSIONALS WHO MAY PERFORM PROCEDURE Registered Nurse, Medical Doctor, Physician’s Assistant, Nurse Practitioner, Practical Nurse, Social Service, Psychology, Dietitian, Optometrist, Ophthalmology, Dental and Audiology services. 9.1.3 EXPECTED OUTCOMES Identification of basic veteran care needs or treatment. Identification of any health care problems that might interfere with the students course of Blind Rehabilitation. Identification of levels of functional status of each veteran. Referrals to physical rehabilitation service as necessary. Identification of educational needs related to health care. Veteran needs are prioritized for further diagnostic testing and/or treatment Coordination of the provision of health care needed by the veteran with other members of the health or Blind Rehabilitation interdisciplinary team. Development of a plan of care that shall endeavor to maintain the veteran’s health during his/her course of rehabilitation. 9.1.4 CLINICAL INDICATION FOR PROCEDURE The veteran enrolled as a student in Blind Rehabilitation programs of the VA shall have their health status formally and informally assessed from first contact with the organization through their rehabilitation program to discharge. 9.1.5 CLINICAL PROCESS Health assessment is conducted while talking to and observing the veteran during planned meetings. Assessments shall be performed by members of the health care team. The medical case history, physical examination, routine lab work and diagnostic tests are completed or ordered within the first 24 hours following admission, by the attending medical doctor. The Initial Nursing Assessment shall take place within the first 12 hours following admission for the well veteran or according to individual station policy. The veteran who is ill upon admission shall be immediately assessed and appropriate referrals made by members of the health care team. Previous medical records, VIST review and/or BRS records are reviewed. Initiation of appropriate referrals to health care team members. Immediate or outstanding problems or needs are referred to specific disciplines. Medications currently taken by the veteran shall be assessed, documented, and evaluated for appropriateness. Veteran’s knowledge of drug & self-administration procedures and/or assistance required, shall also be assessed. 9.1.6 SETTING/EQUIPMENT SPECIFICATIONS Health assessments are conducted in privacy in the clinical boundaries of the health practitioner’s office, or in the natural setting of the veteran’s room. 9.1.7 DOCUMENTATION Health assessments are documented in the veteran’s hospital clinical record according to station policy. Various flow sheets are incorporated into the documentation as necessary. Documentation includes pertinent background information, the status of the veteran’s needs, problems, capabilities, and limitations. Additional health and medication education as appropriate, and situations described by the veteran and/or observed by the professional health care team shall be documented. Intervention shall be documented by the health care team and will be periodically evaluated during the rehabilitation program according to service and station policy. Documentation will include the need for monitoring referrals for immediate follow-up of medical problems. Documentation of treatment goals are based on the interdisciplinary assessments and are realistic, measurable, and consistent with the patient’s medical problems and his goals during his blind rehabilitation training. 9.1.8 POLICY AND RELATED REFERENCES Refer to reference page 10.0 RECREATION/LEISURE TIME SKILLS DEVELOPMENT 10.1.1 DEFINITION OF PROCEDURE The procedure by which veterans are formally exposed to and are educated in a variety of recreation and leisure skills to enhance their quality of life. 10.1.2 PROFESIONALS WHO PEREFORM PROCEDURE Certified Therapeutic Recreation Specialist (CTRS) BRS Instructors BRS Supervisors 10.1.3 OUTCOMES Veteran develops and demonstrates confidence in ability to organize and participate in recreational and leisure time activities as it applies to his/her individual lifestyle. 10.1.4 CLINICAL INDICATION FOR PROCEDURE All veterans will be individually assessed to determine their level of activity with regard to recreational/leisure time activities. 10.1.5 CLINICAL PROCESS An individual assessment will be completed. A treatment plan based on assessment needs will be developed. The treatment plan will be implemented. Veteran(s) participation in activities/treatment plan An evaluation of process will be completed. A plan for discharge, with the veteran’s input, will be developed. 10.1.6 SETTING/EQUIPMENT SPECIFICATIONS Any in hospital setting (game room, pool, or day room) Any outside facility (bowling alley, golf course, and etc.) 10.1.7 DOCOUMENTATION Results of Comprehensive Recreational Therapy Assessments will be recorded in the medical record via progress notes and final summaries from the aforementioned professionals. 10.2.8 PROFESSIONAL POLICY AND RELATED REFERENCES Refer to reference page 11.0 PROSTHETICS 11.1 PROSTHETIC ISSUANCE 11.1.1 DEFINITION OF PROCEDURE The formal procedure by which prosthetic or assistive devices are prescribed, prepared, and dispensed. 11.1.2 WHO PERFORMS Chief, Blind Rehabilitation Supervisors, Blind Rehabilitation Specialists, Nursing/Medical Doctor, Optometry. 11.1.3 EXPECTED OUTCOMES The device issued meets a need. The device issued will help to overcome the handicap of blindness and/or other physical impairments. The device functions reliably and safely. The veteran demonstrates the ability to use the device effectively. The veteran meets the established VA need and performance criteria 11.1.4 CLINICAL INDICATION FOR PROCEDURE Veterans currently participating in VA Blind Rehabilitation. 11.1.5 CLINICAL PROCESS Both formal and informal assessments are completed and analyzed. Self assessment by the veteran is compared with that of the instructor/clinician. Veteran meets issuance criteria as established by VACO or BRC policies. 11.1.6 SETTING AND EQUIPMENT SPECIFICATIONS Clinical environment within the Blind Rehabilitation Center or natural environment. Equipment to be issued meets accepted industry and VA standards. 11.1.7 DOCUMENTATION Contains a statement as to the results of any evaluations, assessments and instruction, a list of prosthetics recommended for issuance, and follow up recommendations. 11.1.8 POLICY AND RELATED REFERENCES Refer to reference page 11.2 PROSTHETIC ADAPTIVE DEVICE ASSESSMENT 11.2.1 DEFINITION OF PROCEDURE Formal assessment procedures are completed to determine appropriateness of prosthetic device necessary to adjust to blindness. 11.2.2 WHO PERFORMS Blind Rehabilitation Specialists, Supervisors, Nursing/Medical Doctor, Optometry, Research personnel, Engineers. 11.2.3 EXPECTED OUTCOMES The veteran’s eligibility for the prosthetic device will be determined. The veteran’s need for the prosthetic device will be identified. The appropriate device will be identified and the skills necessary to learn to use the device will be determined. Treatment plan options will be developed. Issuance criteria for clinical use will be determined. 11.2.4 CLINICAL INDICATION FOR PROCEDURE Device assessments are requested as needed and/or mandated. 11.2.5 CLINICAL PROCESS Protocol is developed. An electro-mechanical assessment of equipment is completed. Formal and informal assessments (field testing with and without subjects) are completed and analyzed. 11.2.6 SETTING AND EQUIPMENT SPECIFICATIONS Blind Rehabilitation Center and Clinics, clinical environment, field environment are all used. Evaluations are conducted on equipment that meets VA and accepted professional standards. 11.2.7 DOCUMENTATION -Protocol evaluation -Signed informed consent forms -Final report 11.2.8 POLICY AND RELATED REFERENCES Refer to reference page 12.0 BLIND REHABILITATION RESOURCE INSTRUCTION 12.1.1 DEFINITION OF PROCEDURE Participation in the Resource Skills Instruction provides skills and information, which enable the veteran to identify and access community and national resources in order to obtain the maximum level of independence in the home and the community. 12.1.2 PROFESSIONALS WHO PERFORM THE PROCEDURE BRS Instructors BRS Supervisors Other BRS professional staff when appropriate 12.1.3 EXPECTED OUTCOMES Veterans will be able to identify and access the national and community resources essential to enhancing their involvement in the home and community. Veterans will be able to order adaptive devices through catalog and community sources. Veterans will be able to acquire and utilize assistance as needed. 12.1.4 CLINICAL INDICATION FOR PROCEDURE Veterans are assessed upon admission to the comprehensive rehabilitation program and appropriate resources are made available in the areas of need/interest. Instruction is provided in small groups in order to facilitate the exchange of information among veterans and instructor and to promote the development of group problem-solving techniques. Individualized instruction is available to all veterans in order to identify specific areas of interest and to gain access to those resources that are identified. 12.1.5 CLINICAL PROCESS Instruction in resource utilization is part of the inter-disciplinary rehabilitation process. Appropriate resource information will be distributed to the veteran via standard print, large print, braille, or cassette tape. Resource information is provided for areas of blindness, disability, aging, leisure activities, and special interest groups. 12.1.6 SETTING/EQUIPMENT SPECIFICATIONS Resource utilization instruction is conducted in classrooms or the most practical setting. The Resource Class is conducted with consideration for physical, acoustic and visual characteristics of the environment. 12.1.7 DOCUMENTATION Documentation contains results of assessments, veteran’s goals for instruction, instructor’s goals for instruction, specific recommendations, problems noted during instruction, progress toward goals, and adaptations incorporated into the normal curriculum. Recommendations may address the need for further assessment, additional instruction, incorporation of adaptations, or termination of instruction. Instruction in resources is incorporated into the veteran’s comprehensive rehabilitation program and appropriate information and documentation will be provided to the Team Coordinator and other team members regarding the instruction. Veteran progress is orally documented at the veteran’s clinical Review and follows the Service guidelines for reporting at clinical reviews. Written documentation will comply with the time frames and formats established by the Service according to the Service’s policy and procedure manual, the Resource Class guidelines, and the Team Coordinator Responsibilities document. 12.1.8 PROFESSIONAL POLICY AND RELATED REFERENCES Refer to reference page 13.0 TEAM COORDINATON 13.1.1 DEFINITION OF PROCEDURE Formal procedure used to determine the veteran’s needs and develop an individualized blind rehabilitation program. The procedures are intended to increase and facilitate active involvement in a partnership between the veteran and his/her Team Coordinator in establishing the treatment team, goal setting, treatment planning, monitoring progress and coordination of discharge planning. 13.1.2 WHO PERFORMS Blind Rehabilitation Specialists, Supervisors, Blind Rehabilitation Management. 13.1.3 EXPECTED OUTCOMES Identification of designated team coordinator/representative for each veteran. Development of individualized Blind Rehabilitation program. Implementation and ongoing monitoring of treatment and discharge plan. Documentation reporting in a timely manner. 13.1.4 CLINICAL INDICATION FOR PROCEDURE Veterans currently participating in the program are assigned a team coordinator upon entrance into the program. 13.1.5 CLINICAL PROCESS Both formal and informal meetings are utilized with the multidisciplinary team. Both formal and informal methods for communicating progress are utilized. Self-assessment by the veteran is compared to that of the multidisciplinary team. 13.1.6 SETTING AND EQUIPMENT SPECIFICATIONS Blind Rehabilitation Centers. 13.1.7 DOCUMENTATON A written summary of an initial meeting with the veteran will be completed. The veteran’s treatment plan will be completed to include the veteran’s pre-stated goals. Ongoing documentation of the veteran’s progress in the program will be completed daily/bi-weekly. The Blind Rehabilitation discharge summary will be completed. 13.1.8 POLICY AND RELATED REFERENCES Refer to reference page 14.0 GLOSSARY OF TERMS Assistive Technology: Devices used to improve an individual’s functional capabilities. (e.g. speech and communication technology, travel aids, low vision aids, hearing aids, etc.) Blind Rehabilitation Center (BRC): A residential inpatient program that provides comprehensive adjustment to blindness training and serves as a resource to a catchment area usually comprised of multiple Veterans Integrated Service Networks (VISNs). Blind Rehabilitation Specialist (Instructor): DVA Position Title that refers to BROS as well as BRC staff who assess, plan and instruct in one of the BRC disciplines. Designates an instructor with a Bachelor’s Degree (or higher) in one or more of the specialized areas of working with the blind; or a professional, who possesses a Bachelor’s Degree (or higher) in an allied health profession who has expertise in one or more of the specialized areas of working with the blind. Blind Rehabilitation Outpatient Specialist (BROS). A BROS is a multi-skilled and experienced blind rehabilitation instructor who has advanced technical knowledge and competencies in at least two of the following disciplines at the journeyman level: orientation and mobility, living skills, manual skills, and visual skills. A BROS has been cross-trained to acquire broadly based knowledge in each of these BRC disciplines, plus computer access training (CAT). Community Integration: Adjustment activities that help a person gain the attitudes and skills needed to restore involvement in the family and community. This includes but is not limited to participation in social and recreational activities in the community, physical exercise, hobbies, integration into work and school settings, social adequacy within the family, etc. Computer Access Training: The instructional area that teaches the skills necessary to use specialized access software/equipment in order to operate a computer. This includes evaluating the ability of the person served to use large print, synthetic speech, voice recognition or Braille access devices in order to perform word processing functions and other computer related activities. Consumer Education: Veterans are educated on their rights and responsibilities, as well as any VA and non-VA benefits and resources for which they may be eligible. Self-advocacy is promoted in order to achieve positive outcomes in community reintegration. Continuum of Care: Refers to blind rehabilitation training that extends across the veteran’s home environment, local VA facility, and regionally based inpatient training program. Cross-Training: Training that extends beyond one’s formal training and is intended to maximize the instructor’s area of expertise by combining specific instruction from other closely related disciplines. The training is provided by instructors with verifiable competencies in the BRC program disciplines of Living Skills, Orientation & Mobility, Manual Skills, Visual Skills, and Computer Access. Family Training Program: A family member or caretaker is afforded the opportunity to participate in the rehabilitation process for several days near the end of a veteran’s training program as defined and prescribed by the rehabilitation team. The family training program is educational in nature and will follow a normal training class schedule. Participants observe classes and meet with individual instructors, nursing, optometry, and psychology in order to learn about specific changes the veteran made during his or her training program. Participants are educated about blindness in general and receive specific information about their family member’s vision loss. The family member also learns of potential risks in terms of health and safety along with their shared responsibilities when the veteran returns home. They are given an opportunity to enhance their advocacy skills. The Family Training Program is facilitated by the BRC Social Worker or Outreach Coordinator and serves as a major step in helping the veteran and family member achieve a better understanding of each other and the frustrations imposed by blindness. Legal Blindness: Exists when a person’s best corrected central visual acuity in the better eye is less than or equal to 20/200 or, if the central visual acuity in that eye is better than 20/200, that the visual field dimension is less than or equal to 20 degrees at the widest diameter. Leisure Skills: Various social, recreational and avocational activities are available, within the BRC and in the community, that afford an opportunity for veterans to effectively participate and transfer a leisure time interest back to their home and community following rehabilitation. Activities may include attending sporting events, social gatherings, theatrical productions, movies and concerts. Veterans may also participate in golf, fishing, hiking, cards and board games or they may focus on developing a hobby such as leathercrafts, copper tooling, and woodworking. These activities are designed to enhance a blinded veteran’s experience in the BRC program and they promote positive adjustment to vision loss. As such, the activities are offered on a daily basis and veterans are encouraged to utilize the skills, techniques and devices learned during their training classes. Living Skills: The instructional area that addresses the daily tasks necessary to manage everyday activities in order to remain independent. These skills encompass a broad range of activities including personal grooming, food preparation, eating skills, household management, time management and labeling techniques that serve to increase a person’s independence in their home and personal life. They also consist of communication skills where opportunities are provided to learn Braille, typing or keyboarding, handwriting, and the use of assistive technology to accomplish tasks such as storing and retrieving information, reading, managing financial records, etc. Manual Skills: The instructional area that is designed to assess and enhance skills in all aspects of sensory awareness with an emphasis on adaptive and safety techniques. Skill training focuses on organization, tactual awareness, spatial awareness, memory sequencing, problem solving, confidence building and integrating visual skills. Activities range from basic tasks using hand tools to advanced tasks using power tools and woodworking machinery. Instructional areas include leatherwork, copper tooling, home mechanics, small engine repair, woodworking, weaving and ceramics. It is not considered to be vocational training although some veterans have developed a vocation or hobby through participation in this skill area. Ocular Health Examination: An examination conducted by a licensed eye care practitioner that identifies the level of and reasons for a person’s visual impairment. The examination includes a refraction to establish best corrected central visual acuities (not using eccentric viewing). It also includes a thorough assessment of the visual system and ocular health to establish the diagnosis primarily responsible for the impairment and to ensure that all ocular and visual disorders are being appropriately managed. The examination provides the licensed eye care practitioner with information essential to conducting and/or directing additional assessments and management strategies centered on the delivery of optimal visual impairment rehabilitative services. Optical Low Vision Devices: Any device that alters the image, focus, size (magnification), contrast, brightness, color or directionality of an object through the use of lenses or other technology. Such devices include but are not limited to: eyeglasses (with or without tint), microscopic spectacles, hand held magnifiers, stand magnifiers, telescopes (monocular or binocular), headborne lenses, minifiers, prisms, and closed circuit televisions (CCTV). Orientation and Mobility: The instructional area where persons are trained to effectively use their remaining senses in combination with protective techniques and assistive devices that enable the individual to independently travel in a safe, efficient and confident manner in both familiar and unfamiliar environments. Travel devices include the long cane, support canes, telescopic aids, sunglasses, and alternative mobility devices such as walkers. Travel situations include navigating inside restaurants and stores, safely crossing streets at controlled and uncontrolled intersections, locating landmarks, using public transportation, etc. Preferred Practice Patterns: Statements developed as a guideline for blind rehabilitation specialists that specify procedures, clinical indications for performing the procedure, clinical processes, setting, equipment specifications, documentation aspects and expected outcomes. Prosthetic Activity: Includes any Prosthetic Treatment Center, Prosthetic and Sensory Aid Service, or section established in a VA facility that is charged with the responsibility for the Prosthetic Program at that facility. Prosthetics: A broad term used to identify the total concept of the fields of prosthetics, orthotics, sensory aids, aids for the blind, medical equipment, medical supplies, components, and repairs. Sensory Aids: Items/devices which are designed to compensate for deficiencies in sense organs (e.g. low vision aids, hearing aids, speech and communication aids, long cane, etc.) Veteran’s Health Administration (VHA): One of three agencies comprising the Department of Veterans Affairs that has as its’ primary mission the provision of healthcare to America’s veterans. Visual Impairment Services Team (VIST): A team comprised of health care and allied health care professionals charged with the responsibility for determining the comprehensive services required by a visually impaired veteran. Representatives may include but are not limited to: ophthalmology, optometry, medicine, audiology and speech pathology, prosthetics, social work, nursing, administration, vocational rehabilitation, adjudication and veterans benefits. The VIS Team may also include a representative from the local Blinded Veterans Association as well as a representative from a local agency for the blind. Visual Impairment Services Team (VIST) Coordinator: The VIST Coordinator is a case manager who has major responsibility for the coordination of all services for visually impaired veterans and their families. Duties include providing and/or arranging for the provision of appropriate treatment modalities (e.g. referrals to Blind Rehabilitation Centers and/or Blind Rehabilitation Outpatient Specialists) in order to enhance a blinded veteran’s functioning level. Other duties include identifying new cases of blindness, providing professional counseling, resolving problems, meeting specific objectives established by the VIS Team, arranging VIST Reviews, and conducting educational programs relating to VIST and blindness. Visual Skills: The instructional area that addresses the needs of veterans with partial vision to gain a better understanding of their eye problems through patient education. Instruction also focuses on teaching veterans how to effectively utilize their remaining vision through the use of low vision scanning and eccentric viewing techniques. It includes assessment and training with special optical aids and devices that are designed to meet the various needs of the person being served. These needs may include lessons that employ a variety of visual aids, devices, special equipment, and training modalities that address near, intermediate, and distance tasks as necessary in order to read printed material, perform activities of daily living, engage in home repairs, travel independently, etc. VIST Review: A process that includes a physical examination, eye exam, and VIST Coordinator interview during which needs are identified and the veteran is advised of the full range of services and/or benefits for which he/she is eligible. The VIST assessment will address a patient’s history, current skill level, adjustment to blindness issues and current needs. It will result in a description of the veteran’s functional capabilities and limitations. This will result in the formulation of a treatment plan which includes recommendations for other needed exams, services, and follow-up as indicated. Wellness Education: Comprises learning activities that are intended to improve the veteran’s health status. These include but are not limited to healthcare education issues such as: diabetes education; self-management of medication(s); nutritional instruction; and compliance in order to maintain a high level of personal well being and independence. It may also include exercise programs and training in the proper use of exercise equipment with the necessary adaptations and modifications. Emphasis is placed on consistency and repetition, with the goal of continuing the exercise program after rehabilitation. A wellness program may also cover other activities outside of the realm of physical exercise. This may include aspects of relaxation therapy, coping with stress, smoking cessation and other overall health enhancing activities. 15.0 REFERENCES AND POLICIES Department of Veterans Affairs, Veterans Health Administration Manual M-2, Part XX111, “Blind Rehabilitation Service”. August 19, 1991. Department of Veterans Affairs, Veterans Health Administration Manual M-2, Part IX, “Prosthetic and Sensory Aids Service”, Chapter 5, “Aids for the Blind”, May 29, 1986. Blind Rehabilitation Service Policy and Procedure Manual Blind Rehabilitation Service Team Coordinator Document Blind Rehabilitation Service Family Program Guidelines Nursing Service Standards of Nursing Practice AMH. 1989 and 1993 Optometry Service Manual Clinical Privileges for Optometry Staff Hospital Bylaws for Privileges for Optometry Staff Fay, Eleanor, Clinical Low Vision, Little Brown & Company, Boston 1984 Freeman, Paul B. and Jose, Randall, The Art and Practice of Low Vision, American Foundation for the Blind, New York, 1983. Mehr, Edwin and Freid, Alan, Low Vision Care, The Professional Press, Inc., Chicago 1975 JCAHO Manual on Rehabilitation Programs Accreditation Manual For Hospitals, 1988, RH. 1.3 Commission on Accreditation of Rehabilitation Facilities 52 35 BRS Preferred Practice Patterns 45 BRS Preferred Practice Patterns