VHA PROSTHETIC CLINICAL MANAGEMENT IPROGRAM (PCI\'1P) CLINICAL PRACTICE RECOMMEN[;IATIONS PRESCRIPTION AND PROVISION OF DAIL. Y LIVING AND MOBILITY DEVICES FOR LEGALLY BLIND AND VISUALLY-IMPAIRED VETERANS I. POLICY The purpose of the clinical practice recommendations is to assist practitioners in clinical decision-making, to standardize and improve the quality of patient care, and to promote cost-effective prescribing. II. BACKGROUND The Under Secretary for Health directed VHA's Prosthetic and Sensory Aids Service Strategic Healthcare Group to establish a Prosthetic Clinical Management Program (PCMP). The objectives are to coordinate the development of clinical practice recommendations for prosthetic prescription practices and contracting opportunities to assure technology uniformity and ease of access to prosthetic prescriptions and patient care that will lead to valid outcome measures and analysis for research purposes. A work group with input from selected clinicians with expertise in Blind Rehabilitation, and representatives of veterans' consumer groups, was formed to develop clinical practice recommendations for the use, training and issuance of aids to be used to assist legally blind and visually-impaired veterans in overcoming the impairments associated with blindness and vision loss. VA Blind Rehabilitation Centers (BRC), Blind Rehabilitation Outpatient Specialist (BROS), and Visual Impairment Services Team (VIST) programs were developed to care for veterans that meet the criteria for legal blindness. However, some veterans with significant visual impairment, who are not legally blind, may benefit from some items categorized as aids for the blind (AFTB). Those eye care professionals (Ophthalmologists and Optometrists) that serve the abovementioned veterans in a variety of clinical settings may prescribe appropriate AFTB as indicated. Generally, Blind Rehabilitation Specialists, BROS, and VIST Coordinators (whose scope of practice and level of expertise include the ability to determine appropriateness of prosthetic items), may request that an AFTB be issued. Such request should be made after completion of an assessment and training protocol based on professional standards. VIST may also request replacement issue for an item previously issued by a qualified clinician. There must be documentation about the justification for issuance and i " .,ca ""'",, evidence of appropriate patient training in uses of AFTB, as well as documentation verifying VHA outcome measures (Attachment). III. CLINICAL PRACTICE RECOMMENDATIONS A. Had a stated goal(s) that required the use of an AFTB. B. Expressed an interest in using an AFTB to accomplish the goal(s). C. Demonstrated the ability to independently and safely use the AFTB to effectively meet the stated goal(s). 1. Prior to prescribing an AFTB, the veteran should have the opportunity to evaluate appropriate devices to accomplish the stated goal(s), including conventional optical devices, optical low-vision devices (OLVD) and non-optical devices. 2. The AFTB must prove to be the most efficient and effective means of utilizing the veteran's remaining vision to accomplish the stated goal. 3.Visually-impaired veterans in Priority 5 and 7 with the following conditions may be issued AFTB: a. Those that have visual impairment resulting frorn the existence of another medical condition for which the veteran is receiving VA care, or which resulted from treatment of that medical condition. b. Those with significant functional or cognitive impairment evidenced by deficiencies in the ability to perform activities of daily living, but not including routinely occurring visual impairments. c. Those that are so severely visually-impaired that the provision of AFTB is necessary to permit active participation in their own medical treatment. D. Prior evaluation by Audiology with dispensing of hearing aids is preferred before enrollment in a visual rehabilitation program since many AFTB require auditory input (i.e., talking watch, talking blood glucose or blood pressure monitor). On occasion, over-the-counter Amplification/Listening Devices may be needed to assist uncorrected hearing-impaired veterans during the visual rehabilitation process; however, these veterans should ultimately .'w' "'" ",.ji "I., i'..cl.,"dl~,"b. be referred to Audiology for more in-depth evaluation to reduce the impact of dual sensory impairment. Non-Optical Devices The following represent general categories of non-optical devices that may be issued as aids for the blind if, after assessing need, a qualified clinician recommends issuance. It is not meant to be an exhaustive list of devices, but rather a broad listing of categories of aids presently available. A. Memo OrGanizers: The general purpose of these devices is to assist people with the organization of their day-to-day activities. Use of recording devices for blind individuals makes it easier to store and retrieve information in a more efficient and timely manner. 1. The device must meet the definition of an "aid for the blind" as outlined in the VHA Handbook 1173.5. 2. General guidelines for consideration should be: 0 Amount of material that needs to be organized (i.e. work, school, volunteer work) 0 Need for portability 0 Ability to store and retrieve the information 0 Ability to use the keypad and/or operate those functions of the device necessary to achieve the veteran's goals 0 Ability to hear and distinguish the recorded message In all cases initial instruction and training on the device should be provided. Although a training tape comes with the device, the veteran should be able to demonstrate the ability to operate necessary functions of the device with an acceptable display of accuracy. B. Time Pieces: The general purpose for these devices is to assist blind individuals with the management of time. This will be done by the use of talking, Braille and/or large print timepieces, depending on degree and type of vision loss, need for contrast and lor veteran's preference. These guidelines should consider both watches and alarm clocks. 1. The device must meet the definition of an "aid for the blind" as outlined in the VHA Handbook 1173.5. 2. General guidelines for consideration should be: 0 Desire and need to manage time ,.0, "., .,.. CJ Ability to tell time with the device CJ Ability to set the device is desirable but should not be mandatory 3. In most cases instruction and training on these devices should be provided. The veteran should be able to demonstrate the ability to tell time with the device. The ability to set the time piece is desirable but should not be mandatory when considering issuance. C. Letter WritinG Guides: The general purpose of these devices is to assist blind individuals with handwriting and note taking. This may be done by the use of string boards, writing boards, plastic templates and/or bold-lined paper. 1. The device must meet the definition of an "aid for the blind" as outlined in the VHA Handbook 1173.5. 2. General guidelines for consideration should be: CJ Desire and need to correspond in writing to oneself or others CJ Ability to use the device CJ Instructor recommendation and veteran's preference as to which aid maximizes the veteran's performance. 3. In most cases instruction and training on these devices should be provided. The veteran should be able to demonstrate the abilrty to write legibly with the device. D. Check WritinG Guides: The general purpose for these devices is to assist blind individuals with check writing and financial management. This will be done by the use of check writing guides and templates. 1. The device must meet the definition of an "aid for the blind" as outlined in the VHA Handbook 1173.5. 2. General guidelines for consideration should be: CJ Desire and need to write checks CJ Ability to use the template to fill out a standard size check 3. In most cases instruction and training on this device should be provided. The veteran should be able to demonstrate the ability to write legibly with the device. E. SiGnature WritinG Guides: The general purpose for these devices is to assist blind individuals with signature writing, which will be done by the use of signature guides and templates. """ "' 1. The device must meet the definition of an "aid for the blind" as outlined in the VHA Handbook 1173.5. 2. General guidelines for consideration should be: I:J Desire and need to produce a legal signature I:J Ability to use the template to legibly produce a legal signature 3. In most cases instruction and training on these devices should be provided. The veteran should be able to demonstrate the ability to write legibly with the device. F. Hot Bevera_qe Maker. The general purpose for these devices is to assist blind individuals to safely heat water without the use of a conventional stove or microwave. 1. The device must meet the definition of an "aid for the blind" as outlined in the VHA Handbook 1173.5. 2. General guidelines for consideration should be: I:J Difficulty with safely using conventional stovetop I:J Ability to safely operate the beverage maker I:J Desire and need to independently prepare instant food.s and beverages 3. In most cases instruction and training on these devices should be provided. The veteran should be able to demonstrate the ability to operate the device safely. G. Kitchen Timers: The general purpose for these devices is to assist blind individuals with the timing of food doneness, medication management, appointments, etc. This will be done by the use of talking, Braille andlor large print timers, depending on degree and type of vision loss, need for contrast and lor veteran's preference. 1. The device must meet the definition of an "aid for the blind" as outlined in the VHA Handbook 1173.5. 2. General guidelines for consideration should be: I:J Desire and need to use a timing device I:J Ability to set the device I:J Ability to hear the alarm '" WI 3. In most cases instruction ar)d training on these devices should be provided. The veteran should be able to demonstrate the ability to operate the device accurately. H. Liquid Level Indicators: The general purpose for these devices is to assist blind individuals with the pouring of both hot and cold liquids. 1. The device must meet the definition of an "aid for the blind" as outlined in the VHA Handbook 1173.5. 2. General guidelines for consideration should be: 0 Desire and need to independently pour hot and/or cold liquids 0 Ability to safely use the device 3. In some cases instruction and minimal training on these devices should be provided. The veteran should be able to demonstrate the ability to operate the device. I. Bar Code Readers: The general purpose for this device is to assist blind individuals with the labeling and identifying of a variety of items, such as clothing, medicines, food items, etc. 1. The device must meet the definition of an "aid for the blind" as outlined in the VHA Handbook 1173.5. 2. General guidelines for consideration should be: 0 Veteran should have minimal functional vision 0 User should have a large volume of labeling needs 0 Ability to hear the recorded messages 0 Ability to physically manipulate the device 0 Ability to independently record, playback, erase and search for recorded labels 0 Ability to independently locate the scanning bar on packaged goods 0 Ability to use the help, memo, date/time and memory modes is desirable but should not be mandatory. 3. In all cases initial instruction and training on this device must be provided. The veteran should be able to demonstrate the ability to operate the device in order to meet their intended goals. c, , ,. , , ., ",""""", ". Mobilitv Devices Patients must meet the clinical definition of blindness. A. Mobilitv canes for blind JJeoJJle: The general purpose of these devices is to assist blind people with obstacle detection, provide some measure of protection from obstacles, and to extend the tactual sense of the user in order to provide information about the environment. (Some blind people may also require a support cane. There are several types of support canes available with red and white markings conforming to specifications as a cane for the blind. Support canes should be issued initially upon recommendation of an appropriate clinician (e.g., Physical Therapist). Some blind people may only need a cane for identification purposes.) Included in this general category are rigid canes (the Long Cane), folding or collapsible canes, and support canes. 1. The device must meet the definition of an "aid for the blind" as outlined in the VHA Handbook 1173.5. 2. The device should be constructed, at minimum, following the guidelines established by the National Academy of Sciences (1971). (See Foundations of Orientation and Mobility, Welsh and Blasch, 1980, ch.11) 3. General guidelines for consideration should be: 0 Need for an obstacle detector 0 Need for identification as a blind person 0 Need to acquire tactual information about the environment 0 Ability to properly utilize the device in various travel environments 0 Need for support cane specifically prescribed by a qualified clinician. 4. In most cases instruction and training on the device must be provided by a university trained Orientation and Mobility (O&M) Specialist. (except in cases where the user is being issued a replacement cane (of exact length and type) and has completed a course of training in O&M given by a university trained O&M Specialist). The veteran must be able to demonstrate a level of safety and skill commensurate with the intended scope of independent travel. The only exception being when a cane is issued for " co." ill"'"" ,.", ","","'.. identification purposes only and it has been documented that the user and the issuer agree that the device is not to be used for independent travel. B. Cane Tips: The general purpose for these devices is to provide a replaceable, specific purpose tip for a blind cane. 1. The device must meet the definition of an "aid for the blind" as outlined in theVHA Handbook 1173.5. 2. General guidelines for consideration should be: 0 Type of cane used 0 Environment in which the cane and tip will be used 0 Ability of the user to utilize unique feature of the cane tip 3. In most cases instruction and training on these devices must be provided by a university trained O&M Specialist. The veteran should be able to demonstrate the ability to safely and efficiently utilize the device in the manner for which it was intended. C. Other Mobility Devices: The general purpose for these devices would be to amplify or enhance sensory information; extend the user's range of travel; and increase the safety of the traveler. Some examples of the variety of devices are: sound enhancing or localizing devices, laser canes, other electronic or mechanical aids. 1. The device must meet the definition of an 'aid for the blind' as outlined in the VHA Handbook 1173.5. 2. General guidelines for consideration should be: 0 Demonstrated ability to use the device properly and safely 0 Need for the device within the scope of normal expected usage 0 Extent to which the device outperforms conventional mobility tools available. 3. Instruction and training on these devices will be provided. The veteran must be able to utilize the device to achieve the desired result in a safe manner. ~EE~~~~~/DISAPPROVED: Jona ~ ./ k4.e an B. Perlin, MD, PhD, MSHA, FACP Date: f~ / f'- Pi'I "" , ."lIiil..:""""" """' ATTACHMENT VHA OUTCOME MEASURES A. Veteran-specific abilities At the conclusion of training, the veteran must be able to demonstrate the ability to independently and safely operate the AFTB to achieve the stated goa/(s). Basic VHA outcome measures for AFTB may include the following: 1. Demonstrated ability to operate and effectively utilize the basic features of the device in a safe and efficient manner. 2. Demonstrated understanding of the appropriate potential uses of the device, although those options are not initially needed. 3. Demonstrated ability to appropriately connect attachments and utilize special auxiliary features of the device to maximize its use. 4. Demonstrated ability to clean and maintain the device in good working order. B. Rehabilitation-specific capabilities At the conclusion of training, the veteran must be able to demonstrate improved quality of life through the development of skills and capabilities needed for personal independence, and successful integration into the community and family environment. VHA outcomes measures for AFTB may include the following areas, as applicable: 1. Orientation and mobility 2. Living skills 3. Communication skills 4. Activities of daily living (ADL) 5. Independent living 6. Manual skills 7. Visual skills 8. Computer access training skills 9. Physical conditioning 10. Recreation 11. Adjustment to blindness and/or significant visual impairment 12. Group meetings/social interactions NOTE: The VHA Outcome Measures are arrived at through both objective and subjective means. Current research dictates the particular measurement tools or measures utili.!:ed. l ..",. ..", "'.", "" .01"',," ""... ,I