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Cecil introduces the program and vendors

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1 VR Staff Training – Area 4 Effective Delivery of VR Services to Individuals with Hearing Loss
Cecil introduces the program and vendors Cecil thanks to Area 4 and supports (e.g., interpreters, CART, vendors) Cecil explains purpose and goals of this staff training as part of a “pilot training project”

2 Presenters Cecil Bradley - VR Administrator, DVR Stefanie Fenton, VR Staff Interpreter DVR Area 1 (Tallahassee) Valerie Stafford-Mallis – Florida Coordinating Council for the Deaf and Hard of Hearing - Department of Health Cecil introduces key presenters

3 Content of Today’s Program
Deaf & Hard of Hearing Population Descriptions of hearing loss Signs and symptoms Emotional needs Interventions Communication modifications Assistive technology Interpretive services Cecil introduces topics of this training program

4 Content of Today’s Program (cont’d)
Best Practices Purpose of DHH Services Program Interpreting Services Update Hearing Aids Update Prior Approvals Counseling and Guidance Individuals who are Deaf-Blind and DBS Resources + Questions and Answers Vendors and Demonstration of Devices Cecil introduces topics of this training program (Continued)

5 Learning Objectives We will learn to:
Recognize 4 types of individuals with hearing loss Recognize the physical & emotional manifestations of hearing loss Utilize Best Practices in serving this population Understand communication accessibility Select appropriate assistive technology & services Utilize available community resources Cecil introduces key objectives of the training program Cecil mentions that questions from the audience are welcome and will be answered as time permits

6 What We Hear Valerie starts presentation with this slide
Discuss how different noises impact or harm our hearing

7 Unique Aspects of Hearing Loss
Tinnitus Distorted Hearing Hearing things that aren’t there Feelings of fullness Dizziness & vertigo Loss of balance Central auditory processing disorder Otitis media & Otitis externa Valerie continues presentation - Medical Aspects - Also, mention other causes of Hearing Loss (e.g., Deafness at Birth, Reaction to Medication, Head Injury, Noise) Counseling and Guidance– if the consumer mentions some of these symptoms, even if they are only looking for a hearing aid – suggest a follow up with an ENT referral because, if they can be medically treated, removing these symptoms can positively effect communication in the work place. If they cannot be treated, consumer gets disability awareness and education –possibly including information about triggers, etc for disability maintenance.

8 Hearing Loss Descriptors
Deaf Hard of Hearing Late Deafened Deaf-Blind Valerie explains what she will address in regards to different types of hearing loss Briefly discuss why we do not use the word “Hearing Impaired.”

9 Types of Hearing Loss Conductive Hearing Loss Sensori-neural Hearing Loss (aka Neural Hearing Loss) Mixed Hearing Loss © American Speech-Language-Hearing Association Conductive Hearing Loss Conductive hearing loss occurs when sound is not conducted efficiently through the outer ear canal to the eardrum and the tiny bones, or ossicles, of the middle ear. Conductive hearing loss usually involves a reduction in sound level, or the ability to hear faint sounds. This type of hearing loss can often be medically or surgically corrected. Examples of conditions that may cause a conductive hearing loss include: Conditions associated with middle ear pathology such as fluid in the middle ear from colds, allergies (serous otitis media), poor eustachian tube function, ear infection (otitis media), perforated eardrum, benign tumors Impacted earwax (cerumen) Infection in the ear canal (external otitis) Presence of a foreign body Absence or malformation of the outer ear, ear canal, or middle ear Sensorineural Hearing Loss Sensorineural hearing loss occurs when there is damage to the inner ear (cochlea) or to the nerve pathways from the inner ear (retrocochlear) to the brain. Sensorineural hearing loss cannot be medically or surgically corrected. It is a permanent loss. Sensorineural hearing loss not only involves a reduction in sound level, or ability to hear faint sounds, but also affects speech understanding, or ability to hear clearly. Sensorineural hearing loss can be caused by diseases, birth injury, drugs that are toxic to the auditory system, and genetic syndromes. Sensorineural hearing loss may also occur as a result of noise exposure, viruses, head trauma, aging, and tumors. Mixed Hearing Loss Sometimes a conductive hearing loss occurs in combination with a sensorineural hearing loss. In other words, there may be damage in the outer or middle ear and in the inner ear (cochlea) or auditory nerve. When this occurs, the hearing loss is referred to as a mixed hearing loss. 9

10 Mild Moderate Severe Profound
Levels of Hearing Loss Mild Moderate Severe Profound Valerie to discuss differences in the levels (severity) of hearing loss Mention decibels – as in loudness Mention hertz – as in pitch

11 Audiogram Examples Valerie to discuss differences in the levels (severity) of hearing loss using audiogram examples Left – normal and severe Right – two audiograms (top – neural; bottom – mixed) Counseling and Guidance – make sure the consumer can read their own audiogram since they will be getting audiograms to monitor changes for the rest of their life – they need to be able to understand the implications of changes.

12 The Speech Banana Valerie to discuss how different sounds appear on the audiogram and how the customer may experience inability to understand spoken words (speech), depending on the type of hearing loss

13 Working with Individuals who are Deaf
Sense of hearing is non-functional without the use of technological assists May be congenital or acquired deaf vs. Deaf Valerie discusses deafness Cecil may wish to comment on deaf vs. Deaf

14 Working with Individuals who are Deaf
The Big “D” = Deaf Culture Deaf Pride Common Identity American Sign Language Recognition & Acceptance Valerie discusses deafness Cecil may wish to comment on the significance of Deaf Culture

15 Working with Individuals who are Hard of Hearing
Hearing Loss can range from: Mild – Moderate – Severe – Profound Can affect one or both ears Onset is usually gradual but can be rapid Valerie discusses hard of hearing

16 Working with Individuals who are Late-Deafened
Hearing Loss usually severe to profound Occurs after speech and language are fully formed Valerie discusses late-deafness

17 Working with Individuals who are Deaf-Blind
Defined as substantial loss of hearing and vision Does not have to mean total loss of hearing & vision May necessitate a Support Services Provider (SSP) It’s important to know the degree of residual vision and hearing to determine the appropriate type of visual, auditory, or tactile communications methods. Valerie discusses deaf-blindness Cecil may wish to comment; mention that interagency involvement will be discussed later in this presentation Counseling and Guidance – Often, needs will be strongly affected by which sense was lost first – hearing or sight or both at the same time. Casework - For Deaf blind consumers, ask about DBS case and counselor contact information.

18 Impact of Hearing Loss on the Customer
Such Impact Can Be Gradual or Sudden! Emotional Aspects Physical Aspects Relationships Valerie discusses how hearing loss impacts the customer Counseling and Guidance Technology – evaluate knowledge of assistive devices such as alarm clock, FTRI, motion detectors at front door for knocks, etc. Communication - Ask the consumers to evaluate what are more successful and less successful communication settings. Ask the consumers if they have developed coping skills in groups (if not, often feel isolated in family gatherings and work environments). Relationships and Independence - Ask about support systems and personal accommodations for independent living such as bill paying, etc.

19 Emotions Common to Individuals who are Late-Deafened or Hard of Hearing
Five Stages of Grief 1. Shock and Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance Valerie to discuss how customers respond to their own hearing loss. (This slide is revised to emphasize focus on individuals who are late-deafened or hard of hearing. Grief process doesn’t occur with those born Deaf) Also balance with positive experiences of those with hearing loss: (Stevie Question – if there is this – should it be followed by the positive experience of the Deaf person – a culture slide to compare…)

20 Hearing Loss is Linked to:
irritability, negativism and anger fatigue, tension, stress and depression withdrawal from family and social situations social rejection and loneliness reduced alertness and increased risk to personal safety impaired memory & the ability to learn new tasks reduced task performance & independence diminished psychological and overall health Valerie continues to discuss how hearing loss impacts the customer Counseling and Guidance – evaluate for depression if warranted

21 Communicating with Individuals who are Deaf or Hard of Hearing
Sensitivity Courtesy Common sense Shared responsibility between speaker & listener Don’t be afraid to ask Whatever works! Valerie provides a general overview on communicating with customers who have hearing loss

22 Communicating with Individuals who are Deaf or Hard of Hearing
Attention Noisy background Light Visual Obstacles & Foreign Objects Diction and Speech: Pace & Volume Valerie discusses issues and barriers that customers face while communicating

23 Communicating with Individuals who are Deaf or Hard of Hearing
Facial expressions and gestures Conversational transition cues Rephrase instead of repeating Talk TO the Individual, not ABOUT him or her. When in doubt, ASK Be patient, positive, and relax Valerie discusses communication protocol

24 Communicating with a Signer
Get their attention first Gentle tap on the shoulder, wave, or flash light only once Communicating with the Individual Use paper and pen while waiting for the interpreter to show up Use open-ended questions to probe for understanding. Valerie discusses how we should approach and communicate with a customer with hearing loss (This slide was revised by removing these words “stomp on the floor and hand slap a table” because that wouldn’t be appropriate in professional situation)

25 Communicating with a Signer
Always use interpreter for informed consent When the interpreter is present, talk directly to the individual who is deaf, not the interpreter. Don’t talk about the individual in their presence Don’t say “Ask him/her” or “Tell him/her” Maintain eye contact. It is considered rude to carry on a conversation without eye contact. Valerie continues to discuss how we should approach and communicate with a customer with hearing loss

26 Communicating with an Individual who is Deaf-Blind (DB)
Notify the agency/interpreter that the individual is DB Advise agency which mode of communication is needed (visual sign language or tactile sign language) To walk with an individual who is DB, offer an elbow and your forearm. Never push or pull them along. Do not leave individual who is DB alone in an open space. Escort them to a safe place and let them know why you are doing this. Valerie discusses general practices in working with and communicating with a customer who is deaf-blind After this slide, we take a 15-Minute BREAK

27 Assistive Devices Alarm clocks Timers and watches Door signalers Phone/strobe signalers Paging systems Weather Alert systems Visual/auditory/tactile alerts Cecil starts presentation with this slide on assistive devices, and mentions that we have an exhibit here on assistive devices Valerie may wish to comment Counseling and Guidance: discuss activities of daily living to see if there are assistive devices that they are unaware of. Encourage them to become familiar with a common retailer like or other similar site. (Picture from Library Services for the Deaf and HH Website: nashville.gov)

28 Assistive Listening Devices
Pocket sized personal amplifiers TV Listening systems FM Systems Loop Systems Various Accessories Cecil discusses briefly about available devices Valerie may wish to comment

29 Communication Devices
TTY Cell Phones Text/Tablets Amplifier/Clarity/ Cap-Tel/Caption Call Cecil discusses available communication devices, as well as those not shown here. Valerie and Stevie may wish to comment Stevie question – are you going to mention Face time or Purple’s smart phone VP here? Maybe

30 Personal FM System: See the Differences
Cecil talks about differences or options found on personal FM systems Valerie and Stevie may wish to comment

31 One-on-One Text Communication
Cecil talks about UBI-DUO, a text communication device, as the choice for VR purchase and installment in field offices, in this slide. We have UBI-DUO as exhibitors here. Cecil also discusses plans on purchase of Personal FM System for selected field offices statewide Cecil explains how important is it for VR field offices to have these handy. Valerie and Stevie may wish to comment

32 Videophone and Video Relay Service
Cecil presents on this slide. Discusses basic differences. More will be discussed in the afternoon as to their differences and what VR hopes to do with a VRI pilot project in selected field offices in the coming months. Valerie and Stevie may wish to comment Counselor guideline – note from Stevie – lots of Counseling and Guidance is taking place by VRS… should emphasize the rapport of face to face even though it may be difficult to get an interpreter.

33 Free Telecommunications Equipment for
Deaf & Hearing Connection of Tampa Bay Free Telecommunications Equipment for eligible Floridians TTY + Amplifiers/Clarity/Cap-Tel Phones Florida Relay Service Cecil explains about the state telecommunications program for eligible Floridians with hearing loss Cecil mentions that FTRI representative: Deaf and Hearing Connection of Tampa Bay, is here as an exhibitor Valerie may wish to comment We take an hour and 15 minute break for LUNCH!

34 DVR Deaf & Hard of Hearing Services
Role of DHHS at the State Office Field & HQ Consultations and Staff Training Best Practices and CI/BAHA Prior Approvals Hearing Aid MSUP Counselor & Staff Interpreter as a Working Team Guidance from Rehabilitation Act of 1973/504, ADA Unique Services: Interpreting & Hearing Technology Webpage, VRI-Net Cecil provides an overview of office functions Stevie may wish to comment

35 VR Individual with Hearing Loss Served (2010-2011)
Served Placed (26) Hard of Hearing , Deaf , Hearing & Visual* Deaf-Blind* Total , *Both Combined - Classified as Deaf-Blind Per RSA 911 Coding (33/4) Cecil shares data on how many individuals with hearing loss received VR services Stevie Question – there is nothing with one * - what does that mean? (Stevie, thanks. Corrected by Cecil )

36 Buying a Hearing Aid: A Refresher
First obtain Hearing Evaluation Report (Audiogram) & Recommendation from Qualified Audiologists Compare vendor’s price with Manufacturer’s Suggested Unit Price (MSUP) on VR Intranet Discuss with the Individual Customer Vendor Choice for Hearing Aid Fitting: Audiologist or Hearing Aid Specialist Difference between Audiologist & Hearing Aid Specialist Cecil discusses VR best practices in purchasing hearing aids Stevie may wish to comment

37 Best Practices: Hearing Aid Issues
Hearing Loss vs. Vocational Impediments Hearing Aid Prices, Fees, & Warranty Hearing Aid Choices What about a Tele-coil? How often & how many Hearing Aids can VR buy? (Picture from Disability Graphics Website: Cecil continues to discuss VR practices in the purchase of hearing aids Stevie may wish to comment

38 Best Practices: Cochlear Implant/BAHA
Cochlear Implant and BAHA Checklist What Requires State Office Prior Approval? What about Replacements or Repairs? VR Intranet: Best Practices & FAQ Cecil discuss CI and BAHA as well as VR purchase of these hearing (medical) devices Stevie may wish to comment

39 Best Practices: Meeting the Customer
Available Accommodations Interpreting Services Communication Devices Computer Access Real-Time Captioning (CART) (Picture from Cecil discusses available accommodations for customers with hearing loss – these may be discussed with the customer in early sessions Requests for CART are rare; both interpreter services and CART are not provided at same time for just one customer per ADA Technical Paper Valerie and Stevie may wish to comment

40 Best Practices: Meeting the Individual for the First Time
Acknowledging Differences Communication Etiquette Cecil adds pointers on VR best practices when working with customers who have hearing loss Stevie and Valerie may wish to comment

41 Best Practices: Working with the Individual
Good and Clear Communication Importance of Counseling & Guidance Focus: Individual’s Daily & Work Impediments Hearing Aid is not the only Service Case Notes Cecil adds pointers on VR best practices when working with customers who have hearing loss Note: if interpreting provided using interpreter, make a case note to document provision (even if it is a staff interpreter) Stevie may wish to comment (Local VR staff may wish to also comment)

42 Best Practices: Functional Capacities
Mobility Communication Self-Care Self-Direction Interpersonal Skill Work Tolerance Work Skills Cecil adds pointers on VR best practices when working with customers who have hearing loss Note: if interpreting provided using interpreter, make a case note to document provision (even if it is a staff interpreter) Stevie may wish to comment (Local VR staff may wish to also comment)

43 Best Practices: Working with the Individual
Case Notes: What to document? Counseling & Guidance Method of Communication Customer Preferences: Auxiliary Aids & Services Cecil adds pointers on VR best practices when working with customers who have hearing loss Note: if interpreting provided using interpreter, make a case note to document provision (even if it is a staff interpreter) Stevie may wish to comment (Local VR staff may wish to also comment)

44 Best Practices: What to Ask the Individual
Hearing Loss History & Diagnosis Is the Individual Wearing Hearing Aid(s)? How old did the Individual Start Wearing One? How the Individual Adapts to Hearing Loss? How Communicate? Phone? Assistive Devices? Cecil discusses briefly on the importance of asking the right questions to gather information as to how hearing loss impacts the customer’s ability to communicate at home, at school, or at work Stevie may wish to comment (Local VR staff may wish to also comment)

45 Best Practices: What to Ask the Individual
If Working, What Does the Individual Do? Are there any Impediments on the Job? Any other Barriers? In the Environment? With People? Are Accommodations Provided on the Job? What Does the Individual Need from VR? Cecil discusses briefly on the importance of asking the right questions to gather information as to how hearing loss impacts the customer’s ability to communicate at home, at school, or at work Stevie may wish to comment (Local VR staff may wish to also comment)

46 THE HEARING HANDICAP INVENTORY - SCREENING FORM
1. Does a hearing problem cause you to feel embarrassed when you meet new people? 2. Does a hearing problem cause you to feel frustrated when talking to members of your family? 3. Do you have difficulty when someone speaks in a whisper? 4. Do you feel handicapped by a hearing problem? 5. Does a hearing problem cause you difficulty when visiting friends, relatives, or neighbors? (From Hearing Handicap Inventory – Cecil discusses this questionnaire that audiologists may ask customers with hearing loss – shares this with the audience as to what typical questions are used to ask the customer regarding his/her hearing loss experiences Valerie may wish to comment (Local VR staff may wish to also comment)

47 THE HEARING HANDICAP INVENTORY - SCREENING FORM
6. Does a hearing problem cause you to attend religious services less often than you would like? 7. Does a hearing problem cause you to have arguments with family members? 8. Does a hearing problem cause you difficulty when listening to TV or radio? 9. Do you feel that any difficulty with your hearing limits or hampers your personal or social life? 10.Does a hearing problem cause you difficulty when in a restaurant with relatives or friends? Cecil discusses this questionnaire that audiologists may ask customers with hearing loss – shares this with the audience as to what typical questions are used to ask the customer regarding his/her hearing loss experiences Valerie may wish to comment (Local VR staff may wish to also comment)

48 Best Practices: VR Services
Referrals from FL School f/t Deaf & Blind Psychological Assessment Vocational Assessment Training Choices On-The-Job Training Job Placement Cecil talks addresses other VR best practices – what to be aware and what we should be mindful in regards to the delivery of services to customers who are Deaf or hard of hearing as provided by our vendors – unique issues Stevie and Valerie may wish to comment (Local VR staff may wish to also comment.)

49 Best Practices: Working with Customers who are Deaf-Blind
Division of Blind Services MOA with Division of Blind Services Dual-Case Referrals Helen Keller National Center Cecil talk about joint DVR DBS efforts to better serve customers who are deaf-blind Cecil mentions HKNC having a regional representative housed in Atlanta; Cecil also mentions local FOP at UF as well as local programs; Cecil also mentions a possible joint project with DBS and HKNC Stevie may wish to comment (Local VR staff may wish to also comment.)

50 Unique Area Practices in the Delivery of VR Services
Referrals Case Management Interpreter Service Arrangements Community Resources and Vendors VR Area staff will be given an opportunity to share their unique practices in the delivery of VR services to customers who are Deaf or hard of hearing. Examples: Who handles Deaf & HH Cases? Procedures for securing interpreter services What happens when an interpreter is not available? Which vendors generally serve this population? Do you have a local medical consultant?

51 Interpreter Credentials
Interpreter Basics How do I use Interpreters? What Interpreter Skills? Maintain Eye Contact American Sign Language Speak in First Person Manual English Direct Conversation Oral Interpreter Credentials National Certification: NAD/RID: NIC, NIC advanced, NIC master; NAD: IV & V; RID: CI, CT, CSC, IT, IC Florida Quality Assurance Screening (QA): I, II, III Stevie discuss interpreter interaction, skills and, credentials.

52 Interpreter Basics (Cont’d)
Hiring Interpreters Two hour minimum for all assignments Two interpreters for jobs that exceed an hour Certification level should match assignment needs Interpreter Disclosure Form (pending) Using Staff Interpreters vs. Vendors Credentials Used in VR offices When hiring from an agency Cancellations and No-Shows From vendors or consumers Stevie discusses interpreter qualifications and expectations (Local VR staff may wish to also comment.)

53 Interpreter Basics (Cont’d)
Vendors From Out of Town Paying for travel Registering for transportation in RIMS Why Family Members Should Not Interpret Documenting in Case Notes Interpreting Manual Updates Stevie discuss practices in arranging for interpreters for customers with hearing loss (Local VR Staff Interpreter may wish to also comment.)

54 Section 504 of the Rehabilitation Act of 1973 (24 CFR Part 104)
Section 504 states that "no qualified individual with a disability in the United States shall be excluded From, denied the benefits of, or be subjected to discrimination under" any program or activity that either receives Federal financial assistance or is conducted by any Executive agency or the United States Postal Service. (A Guide to Disability Rights Law, US Dept. of Justice, September 2005) Cecil discusses the importance of complying with Section 504 of the Rehabilitation Act of 1973 Stevie may wish to comment

55 ADA Title II (28 CFR Part 35) Title II of the ADA requires government entities to make appropriate auxiliary aids and services available to ensure effective communication . You also must make information about the location of accessible services, activities, and facilities available in a format that is accessible to people who are deaf or hard of hearing and those who are blind or have low vision. Generally, the requirement to provide an auxiliary aid or service is triggered when a person with a disability requests it. From: Dept. of Justice ADA Best Practices Tool Kit for State and Local Governments (CH. 3) Cecil discusses the importance of complying with Title II of ADA which is the same as Section 504 of the Rehabilitation Act of 1973, and to address auxiliary aids and services as well as effective communication Stevie may wish to comment This was taken from:

56 ADA Title II (28 CFR Part 35) “Effective communication” means that whatever is written or spoken must be as clear and understandable to people with disabilities as it is for people who do not have disabilities. The effective communication requirement applies to ALL members of the public with Disabilities, including job applicants, program participants, and even people who simply contact state or local government agencies seeking information about programs, services, or activities. Cecil discusses the importance of effective communication - ADA Stevie may wish to comment] References: (DOJ ADA Title II Kit for State & Local Govt’s.) And (Southern California Registry of Interpreters for the Deaf Website Blog)

57 ADA Title II (28 CFR Part 35) You must consult with the individual to determine what Is effective for him or her. Can you name examples of auxiliary aids and services? Cecil discusses the importance of providing auxiliary aids and services as well as providing qualified interpreter as defined by ADA Stevie may wish to comment References: (DOJ ADA Title II Kit for State & Local Govt’s.) And (Southern California Registry of Interpreters for the Deaf Website Blog)

58 ADA Title II (28 CFR Part 35) What is a qualified interpreter as defined by ADA? A qualified interpreter is defined to mean "an Interpreter who is able to interpret effectively, accurately, and impartially both receptively and expressively, using any necessary specialized vocabulary." Cecil discusses the importance of providing auxiliary aids and services as well as providing qualified interpreter as defined by ADA Stevie may wish to comment References: (DOJ ADA Title II Kit for State & Local Govt’s.) And (Southern California Registry of Interpreters for the Deaf Website Blog)

59 What is the Difference? Video Relay Service (VRS) Video Remote Interpreting (VRI) Cecil or Stevie discusses the differences between video relay service and video remote interpreting services Cecil or Stevie mentions VR potential pilot project at 3-4 sites statewide and its purpose

60 Available VR Resources
Deafness & Hard of Hearing - Section 4.18 (also Best Practices Link ) Interpreter Services, Telecommunications & Other Aids - Section 11.09 Hearing Aids Section (also Best Practices Link ) Out-of-State Schools (e.g. Gallaudet, NTID) - Section 13.07 Cecil mentions available VR resources through VRI-Net

61 Contact Information Cecil Bradley, Dana Lachter-Rivera, Deaf and HH Services, Program Resources Section Bureau of Field Services, DVR Phone: (850) (Dana) VP: (Cecil) or (Dana) Valerie Stafford-Mallis, Health Educator Consultant, Florida Coordinating Council for the Deaf and Hard of Hearing, Department of Health Phone: ; (mobile text) Cecil closes session by sharing contact information for all three presenters Cecil encourages VR staff to contact me or Dana if they have any questions or have issues, after they confer with their supervisors first

62 Do You Have Any Questions? Evaluation Let’s Meet the Exhibitors
Closing Remarks Final Comments Do You Have Any Questions? Evaluation Let’s Meet the Exhibitors Communication & Assistive Devices Programs and Services Thank you! Cecil asks audience if they have any questions for the presenters We pass out evaluation forms and ask them to fill them out. Then, Cecil introduces vendors by names again and asks the audience to go and see them and see demonstrations of their devices in the next hour. Remind them of closing time – 4:30p. Thank you!


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