CHAPTER VIII - B

AGENCY SERVICES - DEAFBLIND SERVICES

Mission:

DeafBlind Services staff provides training, consultation, assessment, and technical assistance to each program of the agency to ensure that deafblind customers can fully participate in the agency’s programs and services.

*NOTE:The word deafblind refers to any individual who has a combined vision and hearing loss. Deafblind people have all types and degrees of combined vision and hearing losses. The policy lists elsewhere the types and degrees of combined vision and hearing losses that deafblind customers have.

DeafBlind Services is an ancillary service of the agency. No funds are available from this program to purchase services for vocational rehabilitation (VR), Education Services (ES) or rehabilitation teaching/independent living (RT/IL) customers. The vocational rehabilitation counselor, rehabilitation teacher, or education services coordinator is the case manager and the customer must meet eligibility criteria for Vocational Rehabilitation, Independent Living and/or Older Blind Grant programs, or Education Services programs.

Eligibility:

DBVI customers with combined loss of vision and hearing are eligible for DeafBlind Services regardless of age. DBVI Education Services provide services to deafblind children aged 14 and under. Most children aged 14 and under are primarily served by, the Virginia Deaf-Blind Project for Children and Youth with DeafBlindness (the Virginia Deaf-Blind Project).

Using the following definitions, the DeafBlind Services program tracks customers identified in the following categories:

DeafBlind

• Any individual who has a central acuity of 20/200 or less in the better eye with corrective lenses, or a field defect such that the peripheral diameter of visual field subtends an angular distance no greater than 20 degrees, or a progressive visual loss having a prognosis leading to one or both of these conditions,
• Who has a chronic hearing impairment so severe that most speech cannot be understood with optimum amplification, or a progressive hearing loss having a prognosis leading to this condition; and
• For whom the combination of impairments cause extreme difficulty in attaining independence in daily life activities, achieving psychological adjustment, or obtaining a vocation;
• Who despite the inability to be measured accurately for hearing and vision loss due to cognitive or behavioral constraints, or both, can be determined through functional performance assessment to have severe hearing and visual disabilities that cause extreme difficulty in attaining independence in daily life activities, achieving psychosocial adjustment, or obtaining vocational objectives.

Blind-Hard of Hearing:

• Visual acuity not better than 20/200 central visual acuity in the better eye measured at 20 feet with correcting lenses (legally blind).
• Visual acuity greater than 20/200 but with the widest diameter of the visual field in the better eye subtending an angle of no greater than 20 degrees, or a rapidly progressive eye condition which in the opinion of a qualified ophthalmologist will reduce distance vision to 20/200 or less or 20 degrees field of vision.
• Primarily uses remaining residual hearing which allows the individual to hear and understand speech with little or no visual input, or
• Depends on auditory input aided by hearing aids and/or assistive listening technology and often relies on visual cues such as speech reading, body language, or text translation.
• A 30 db loss or greater (or a speech discrimination score of 75 percent or less) can be severe enough to constitute a disability. Individuals who have a 30 db loss as derived from computing the Pure Tone average 500, 1000, 2000, 3000, Hertz may experience difficulties with aural communication, which may cause a substantial impediment to employment.
• Visual acuity greater than 20/200 (i.e., better vision) but less than 20/70 (i.e., worse vision) in the better eye with best correction or less than a 70 degree horizontal field.
• Visual acuity between 20/100 and 20/200 vision in the better eye with best correction if the person has been unable to adjust satisfactorily to the loss of vision and if it is felt that the person needs the specialized services available through DBVI.
• Is unable to hear or understand speech, is unable to follow conversations unless facing speaker, due to the vision loss is unable to lip read conversation even when facing the speaker, may rely on sign language, sign language interpreters as their first choice for communication access with hearing people, have been identified in the past as being oral deaf or late deafened adults and now would also include many deaf individuals who use cochlear implants and/or English based sign language.

Visually Impaired/Hard of Hearing:

• Visual acuity greater than 20/200 (i.e. better vision) but less than 20/70 (i.e., worse vision) in the better eye with best correction or less than a 70 degree horizontal field.
• Visual acuity between 20/100 and 20/200 vision in the better eye with best correction if the person has been unable to adjust satisfactorily to the loss of vision and if its is felt that the person needs the specialized services available through DBVI.
• Primarily uses remaining residual hearing which allows the individual to hear and understand speech with little or no visual input, or
• Depends on auditory input aided by hearing aids and/or assistive listening technology and often relies on visual cues such as speech reading, body language, or text translation. May use sign language for communication.
• A 30 db loss or greater (or a speech discrimination score of 75 percent or less) can be severe. enough to constitute a disability. Individuals who have a 30 db loss as derived from computing the Pure Tone average 500, 1000, 2000, 3000, Hertz may experience difficulties with aural communication, which may cause a substantial impediment to employment.

Role and Function of DeafBlind Services Staff:

DeafBlind Services consist of a Program Director and a DeafBlind Specialist. Both:

• Provide ongoing consultation and direction to all phases of the agency's programs, which relate to the quality and quantity of services provided to individuals who are deafblind.
• Provide consultation and technical assistance to all DBVI staff in finding solutions to the unique problems of service delivery to customers who are deafblind.
• Develop and/or conduct training and public information programs on deafblindness, including trainings on the effects of having a combined vision and hearing loss.
• Identify resources for in-service training of persons serving individuals who are deafblind.
• Serve as a resource for persons needing information or technical assistance in serving individuals who are deafblind.
• Assess customers who are deafblind to determine their needs for communication aids and specialized equipment and;
• Provide rehabilitation teachers and/or vocational rehabilitation counselors (case managers) with written results and recommendations within ten workdays of completing an assessment.

The Program Director:

• Recommends to other program managers needed policies and procedures when serving customers who are deafblind.
• Acts as agency liaison with the Rehabilitation Services Administration, other government agencies, and public, private and voluntary agencies.
• Develops and monitors the DeafBlind Services administrative budget.
• Monitors agency telecommunications accessibility; and
• Provides consultation, technical assistance and follow-up services for field staff and deafblind customers living in the areas served by the Fairfax, Richmond and Norfolk regional offices, as well as the staff of and deafblind students attending the Virginia Rehabilitation Center for the Blind and Vision Impaired (VRCBVI).

Deafblind Specialist/Southwest Region:

• Provides consultation, technical assistance and follow-up services for field staff and deafblind customers living in the areas served by the Bristol, Roanoke and Staunton regional offices.
• Provides case manager and program director for DeafBlind Services with written results and recommendations of assessment via email and/or AWARE within ten workdays of completing the assessment, and;
• Functions as an interpreter for agency staff on an emergency basis, or in special situations that are approved by the DeafBlind Specialist’s supervisor.

NOTE: Hereafter, the term "DeafBlind Services staff" will be used when denoting services provided by both positions. The term "DeafBlind Services Program Director" will refer to responsibilities only performed by the person in that position.

Referral to DeafBlind Services:

Referrals to the DeafBlind Services staff may occur at any time.

The case manager (a rehabilitation teacher, education services coordinator or vocational rehabilitation counselor) will refer a customer via email and AWARE to the appropriate DeafBlind Services staff, after the individual's case is referred to the case manager. Referrals should be completed per AWARE guidelines. Deafblind customers can be referred to DeafBlind Services if the case manager or customer feels they can benefit from assistance related to their dual vision and hearing loss, especially in the areas of communication, technology and/or independent living. Case managers can consult with DeafBlind Services staff to see if a person is appropriate for DeafBlind Services prior to a making a referral.

DeafBlind Services staff will consult, when necessary, with the case manager within ten workdays of receiving the referral notification.

The DeafBlind Services staff will meet with the customer within 20 workdays. Exceptions will be noted in the customer’s case file documentations through AWARE.

Assessment Results and Recommendations:

Within ten work days of seeing the customer, DeafBlind Services staff will provide the case manager with a written report of assessment results and recommendations via email and on AWARE.

Interpreters:

To request interpreters from the Virginia Department for the Deaf and Hard of Hearing (VDDHH), staff can fill in the interpreting request forms with the necessary information and submit it in a timely fashion (the forms can be found on the VDDHH website at http://www.vddhh.org/ipforms.htm. People need to ensure that the billing address is accurate for the person responsible for promptly processing the invoice so the interpreter can be paid in a timely manner (within 30 calendar days of receipt of the invoice).

For more information on requesting interpreters and their rates, please contact the DeafBlind Services staff and/or VDDHH staff. People can contact VDDHH at 804-662-9502, V/TTY, 1-800-552-7917 V/TTY (both numbers reach VDDHH's front desk), or at isp@vddhh.virginia.gov.

People can use the same phone numbers to schedule, cancel and/or reschedule interpreter services. If they are making a new interpreter request for an assignment via email, they need to email VDDHH at isprequests@vddhh.org.

If people are canceling or rescheduling interpreters via email, they need to email VDDHH at a different email address, isp@vddhh.org. If you are emailing your request for an interpreter cancellation or schedule change, please send an email to isp@vddhh.virginia.gov and put your request in the subject line. For example, if you are cancelling an interpreter request, put “Cancellation: DBVI 1/2/12” in the subject line of the email you are sending to isp@vddhh.virginia.gov.

Referral Procedures to the Helen Keller National Center (HKNC):

All potential referrals to the Helen Keller National Center (HKNC) must first be assessed by DBVI DeafBlind Services staff. Once the customer is determined feasible for services at HKNC, the vocational counselor or rehabilitation teacher (case manager) can obtain an application packet from the appropriate DeafBlind Services staff, or from the Helen Keller regional representative. If people need current information on the HKNC regional representative, they can contact DBVI DeafBlind Services staff, or find the information on the HKNC website at www.hknc.org.

The deafblind customer will complete the application in conjunction with their rehabilitation teacher or vocational rehabilitation counselor whenever possible. DeafBlind Services staff can provide assistance if needed.

The case manager will then send the completed HKNC referral packet to the HKNC regional representative. The HKNC regional representative is responsible for sending the packet to the HKNC New York office. An e-mail will be sent to the appropriate DeafBlind Services staff about any DBVI customer who is being considered for and/or referred to HKNC. For example, if a customer from Richmond is being referred to HKNC, an email can be sent to the DeafBlind Program Director; if someone from Roanoke is attending HKNC, the email can be sent to the DeafBlind Specialist.

To provide continuity in services to DBVI customers who are deafblind or have a combined vision and hearing loss, a note will be made in the HKNC referral packet or cover letter that all relevant HKNC correspondence and progress reports be copied to the appropriate DeafBlind Services staff, with the deafblind customer’s permission and knowledge. (Some customers may not want to share all information about their case with staff.) Updates on customers can also be provided in AWARE and the appropriate DeafBlind Services staff will have access to their customers’ records.

The appropriate DeafBlind Services staff will be listed as a member of the DBVI customer’s transition team to assist the customer to return to his or her home community and/or relocate to another area.

DBVI customers accepted to the HKNC program may benefit from DBVI staff traveling with them to HKNC, so they can observe and become more familiar with HKNC’s programs and services. DeafBlind Services staff can make arrangements with HKNC for DBVI staff to stay for a few days. HKNC currently offers lodging and meals for 30 dollars a night for individuals traveling with the DBVI customer, depending on room availability.

The appropriate DeafBlind Services staff will be included in case conference calls, depending on availability. The DeafBlind Services staff will be available to assist the case manager working with customers who are returning from HKNC to transition into their communities.

Referral Procedures to Virginia Rehabilitation Center for the Blind and Vision Impaired (VRCBVI):

All referrals to VRCBVI require (at minimum) a:

1. VRCBVI referral form from AWARE, called a service authorization, as well as VRCBVI Referral Part Two, also from AWARE.
2. Recent eye report (less than one year old), and a recent medical form (less than six months old if the customer is diabetic and less than one year old for referrals for persons with other illnesses). Please refer to the VR manual, Section 10 for general referral information for all programs.

To plan for and address the accommodation needs of VRCBVI customers in a timely manner, the case manager (vocational rehabilitation counselor or rehabilitation teacher) will need to include the following additional information in the referral packet:

• Documentation on the degree of hearing loss of the individual.
• Listing of any adaptive equipment (i.e., relating to alerting devices, assistive listening devices, current use of hearing aids, cochlear implants, telephone accommodations, etc.) that the person either currently uses or has been recommended to use.
• Interpreter Requirements (Tactile, Visual).
• Information on which devices the person will be bringing with them and which items that they will need while at VRCBVI.
• Copies of DeafBlind Services staff’s assessments and recommendations.
• This information, for all referrals who have a combined vision and hearing loss, will be sent to the DeafBlind Services Program Director as well as the VRCBVI Assistant Director for Administration Services for intake review.

Case Closure:

Thirty days before the case manager (VR counselor, education services coordinator or rehabilitation teacher) closes a deafblind customer’s case, the case manager will send an e-mail to the DeafBlind Services staff in their region to see if any further services are needed related to the customer's vision and hearing loss prior to closure. The DeafBlind Services staff person will review the case file in AWARE to determine if DeafBlind Services have been completed. The DeafBlind Services staff will make appropriate recommendations about what additional services the person may need within the 30 day period. All services must be completed before a case can be closed. A notation will be made in the AWARE case record if the staff is unable to make needed recommendations or close the case within the 30 day period. Case closure for any other reason should be put in the AWARE case record and DeafBlind Services staff should be notified.

A copy of the closure narrative will be e-mailed or sent to the DeafBlind Service staff person so that appropriate AWARE notations can be completed and DB1 (Richmond) or DB2 (Roanoke) caseloads can be updated.

Hearing Aids:

The purpose of a hearing aid is to increase the audibility of sounds (speech and non-speech) so that an individual may hear more sounds than he or she could hear and understand previously. A hearing aid does not “cure” a hearing loss and the benefits will vary among individuals. Much depends on the degree and configuration of the hearing loss, the customer’s cognitive functioning, environmental listening conditions, consistence of use, and other factors. Hearing aids will not make a person’s hearing normal again. With special training, hearing aids will assist a moderately to severely hard of hearing person to discriminate and understand speech and environmental sounds.

Procedure for Reviewing Hearing Aid Recommendations

All hearing aid recommendations for DBVI customers received from audiologists or hearing aid providers are to be sent, along with each customer’s audiograms, to DeafBlind Services staff. It would also be helpful for the vocational rehabilitation counselor or rehabilitation teacher to add a brief sentence or two explaining what the customer's environment involves. For example, does the customer need the hearing aids for work? Will the customer be involved in many group meetings or in a noisy environment? Or will the customer mostly be at home in a quiet listening environment? Information about the customer's listening environment would be very helpful in determining what types of aids will fit their needs.

DeafBlind Services staff will send customers’ hearing aid recommendations and audiograms to the Department of Rehabilitative Services agency audiologist. This person will review each recommendation to ensure that the aids are appropriate for each customer and that audiologists or hearing aid providers are charging standard rates used within the Department of Rehabilitative Services. Once the audiologist approves the hearing aid recommendations, the audiologist will send the recommendations to DeafBlind Services staff, who will forward them to the case managers to process. This is to ensure that DBVI is following standard procedures used for hearing aid purchases within the Department of Rehabilitative Services.

Exceptions to the policy include:

• Hearing aids and services provided through Starkey’s Hear Now Program (these are provided free except for an application fee), and
• Hearing aids and services purchased through James Madison University’s Speech, Language and Hearing Laboratory for low-income Virginia residents since these services are provided at a significantly lower fee than most hearing services.

Otological Examination:

An otological examination is for the purpose of diagnosing and treating medical conditions associated with hearing loss.

Audiological Examination:

The audiological examination assesses hearing function, the reception of sound, the need for amplification, aural therapy, and other factors related to the customer’s hearing loss. If the customer requires a hearing aid, the audiologist will make this recommendation. If the customer already wears an aid, the audiologist can decide whether or not the present aid is satisfactory, or should be repaired or replaced.

Diagnostic Evaluations Required:

An audiological evaluation must be completed by a licensed audiologist in a sound-insulated booth prior to the purchase of hearing aids. An evaluation older than six months is expired and must be re-administered. An otological examination by a licensed otolaryngologist (a medical physician specializing in the treatment of diseases of the ear), is recommended if certain conditions are present in order to determine appropriate medical treatment. These conditions are:

1. visible congenital or traumatic deformity of the ear
2. history of active drainage from the ear within the previous 90 days
3. history of sudden or rapidly progressive hearing loss
4. acute or chronic dizziness
5. unilateral hearing loss
6. audiometric air-borne gap equal to or greater than 15 decibels at 550 Hz, 1000 Hz, and 2000 Hz
7. visible evidence of significant cerumen or a foreign body in the ear canal, or
8. pain or discomfort in the ear.

Medical professionals providing these services must participate in the Department of Rehabilitative Services procurement program.

Exceptions: All individuals 18 years and younger must be medically examined by an otolaryngologist prior to purchasing hearing aids. For individuals over the age of 18, examinations by an otolaryngologist or otologist is not necessary if a previously diagnosed hearing problem that resulted in deformity of the ear or unilateral hearing loss has been stable.

The vocational rehabilitation counselor or rehabilitation teacher will consult with DeafBlind Services staff prior to the audiological evaluation in order to assess the need for hearing aids. The aids should be compatible with assistive listening devices. Customers with a combined vision and hearing loss have a reduced ability to speech read and therefore the use of assistive listening devices has proven to be very beneficial. In order for customers to use assistive listening devices, hearing aids must have a telecoil (t-coil or t-switch). This feature is not on all hearing aids and should be requested for all customers who have a combined vision and hearing loss.

Hearing Aid Evaluation:

Digital hearing aids are very flexible and can be programmed for a wide variety of hearing losses. During the hearing aid evaluation, the audiologist should determine the most appropriate style for the customer’s auditory needs, keeping in mind their physical limitations. Some styles are easier to insert in the ear and maintain because they are larger and easier to handle. This is a very important consideration with customers who have dexterity, cognitive and/or visual limitations. The audiologist may obtain additional measurements such as Loudness Discomfort Levels, Most Comfortable Levels for speech and total stimuli, and word recognition scores in quiet and noisy situations. In addition, the client may be interviewed using a standardized questionnaire that identifies specific hearing difficulties that will be targeted for improvement with amplification.

Hearing Aid Purchases

When hearing aids are purchased, the following must be provided and included in the prices of the aid(s):

• Hearing aid orientation (to teach the customer proper use and care of the hearing aids)
• Follow-up progress check(s) within 30 days of fitting
• Necessary batteries
• Thirty-day trial period
• Programming adjustments for the first six months, at no charge
• Processing repairs during the manufacturer’s warranty, at no charge
• In-house repairs for the first year, at no charge

If you have questions regarding otological or audiological recommendations, please consult DeafBlind Services staff.

Insurance Coverage for Audiological Examination and Hearing Aids:

Some insurance companies will pay for the cost of the audiological examinination. Some require a referral from a medical physician (primary care physician or otologist) before they will pay. Check the customer’s insurance coverage to see if this is a covered service. There are a few insurance companies that provide some coverage for hearing aids and this may increase in the future. Check with the customer’s insurance company.