A Scoping Review of the Evidence on Disability Accommodations Targeting Equitable Communication Access in Health Care

Abstract

Purpose:

The Americans with Disabilities Act (ADA) of 1990 protects the civil rights of people with disabilities, including their right to effective communication and equitable health care access through accommodations. The ADA website lists examples of accommodations (e.g., qualified notetaker, hearing amplifiers, cued speech interpreters), but no literature is cited to support this list. Scientific evidence is critical to advancing both the effectiveness and widespread implementation of accommodations. We scoped the literature on interventions supporting equitable communication access (accommodations) for adults with communication disabilities (CDs) in health care settings. We asked what accommodations have been studied, for what CD populations, and how they have been studied.

Method:

We used a scoping review approach and conducted searches using MEDLINE, CINAHL, and Embase databases. Two reviewers independently screened abstracts and full texts indexed between January 1, 2003, and August 1, 2024. Data on accommodation type, CD-related health condition, setting, health care workers involved, evidence type, study design, and outcome were collected.

Results:

Screening of 1,614 articles identified 58 investigations of 10 communication accommodations in health care settings. The range in number of publications rose from 0–2 to 2–9 over the 11-year period. The three most studied accommodations were customized plan, communication strategies, and augmentative and alternative communication aids (each 21%–22% of studies). Most investigations addressed populations with single CD-related conditions (e.g., aphasia), were descriptive (52%), and had sample sizes ≤ 50 participants. Speech-language pathologists infrequently provided or implemented accommodations (12% of all health care workers involved, by type of worker). Findings were typically positive, but outcome measures were heterogeneous.

Conclusions:

The 10 researched accommodations addressed a wider range of CD populations as compared to accommodations found in policy documents, highlighting an opportunity to align policy and evidence. While accommodation studies generally yielded positive results, their small sample sizes, descriptive focus, and limited quantity suggest this research is early in its development. We outline potential strategies to advance knowledge on the implementation and effectiveness of communication accommodations in health care settings.

Provision of accommodations for effective health care communication is a civil right for people with communication disabilities (CDs). The Americans with Disabilities Act (ADA) of 1990 and Section 1557 of the Affordable Care Act state that health care organizations must provide auxiliary aids and services and reasonable modifications supporting communication (communication accommodations) to ensure equitable health care access (U.S. Department of Justice Civil Rights Division, 2020). In addition, health care accreditation and regulatory agencies such as the Joint Commission and the Centers for Medicare & Medicaid Services acknowledge effective communication as essential to high-quality health care and equitable access for people with CDs (Centers for Medicare & Medicaid Services, 2022; Joint Commission, 2010).

Despite multiple federal protections, ineffective health care communication encounters persist. Adults with CDs report numerous communication challenges in accessing their health care. For example, adults with CDs report that providers talk around them and do not include them in conversations about their care (Agaronnik et al., 2019; Iezzoni et al., 2004; Morris et al., 2013). Additionally, they struggle to understand providers' communication and report providers infrequently use their essential communication modalities and strategies (Agaronnik et al., 2019; Iezzoni et al., 2004; James et al., 2022; Morris et al., 2013). Adults with CDs also lack a means to express basic care needs and raise an alarm during inpatient hospital stays (Hemsley et al., 2016).

One challenge to providing accommodations may be a paucity of evidence on what accommodations to offer, and how to implement this service. For example, the federal ADA Effective Communication website includes examples without a body of evidence supporting the sample list of accommodations. Additionally, the policy protects all people with CDs but many of the accommodations listed are hearing oriented. These examples include “qualified notetaker; oral interpreter, cued-speech interpreter, or tactile interpreter; real-time captioning; written materials; qualified speech-to-speech transliterator (a person trained to recognize unclear speech and repeat it clearly)” (U.S. Department of Justice Civil Rights Division, 2020).

Improving effective communication for equitable health care access is an opportunity for speech-language pathologists (SLPs). The American Speech-Language-Hearing Association's vision statement is “Making effective communication, a human right, accessible and achievable for all.” Additionally, SLPs have immense expertise in communication disorders. However, it is unknown how much SLPs have been involved in studies on accommodations targeting equitable communication access in health care.

In this investigation, we scoped the literature on interventions supporting equitable communication access in health care settings to answer the “what” and “how” of accommodations, including the role of SLPs. We asked what accommodations have been studied, for what CD-related health conditions, and how they have been studied including health professionals involved. We examined our findings in the context of policy and practice to identify opportunities to advance this body of research.

Method

We adopted a scoping review approach to identify the extent, range, and nature of the evidence on communication accommodations (Arksey & O'Malley, 2005; Tricco et al., 2018). We aimed to identify gaps in this heterogeneous literature and inform future research. In line with Arksey and O'Malley (2005), evaluating the quality of research and appraising individual study findings was not a goal of this review. We describe our methods using the Arksey and O'Malley five-step methodological framework. This scoping review did not require institutional review board approval as it involved analysis of existing published literature, with no primary data collection or direct involvement of human subjects.

Stage 1: Identifying the Research Question

Our high-level research question was, “What is the state of the literature on interventions supporting equitable communication in health care?” More specifically, we sought to identify (a) what accommodations have been studied and for which CD-related health conditions and (b) how accommodations have been studied (the setting, health care providers involved in implementing them, research methods, outcomes measured, and the direction of primary findings).

Stage 2: Identifying Relevant Studies

We worked with a medical librarian from the University of Vermont to iteratively design and refine the search strategy. Based on our research question and preliminary readings of articles, we defined our search term template as, “Health care setting & intervention/accommodation & health condition related to CD & Approach.” We then consulted the Medical Subject Headings database to identify appropriate key words. Next, we searched MEDLINE to locate relevant articles and other key words and index terms used in the literature. From text words contained in the titles and abstracts of relevant articles, we refined the full search strategy for MEDLINE, CINAHL, and Embase (the full search strategy can be found in Appendix A). We conducted two searches using the full search strategy. The first was run on June 30, 2023, for articles indexed between January 1, 2003, and June 30, 2023. A second search was conducted on August 1, 2024, for articles indexed between July 1, 2023, and August 1, 2024, to update findings after a year elapsed between completion of the first search and the publication review process. Additionally, we included articles found throughout the process based on author knowledge and citation searching (n = 30).

Stage 3: Study Selection

Following the search, we uploaded citations into Covidence 2023, a web-based collaboration software platform for literature reviews (Veritas Health Innovation, n.d.). The team reviewed and provided feedback on inclusion and exclusion criteria addressing timeframe, type of intervention, group, study type and design, and settings. We included studies on adults age 18 years and older with CDs in hearing, speech, language, voice, and cognition across health conditions. The concept of interest was a communication accommodation as defined by an intervention supporting communication access to health care. We excluded sign language interpreters, as these services are typically provided under language interpretation services in health care settings. We also excluded studies describing communication access in health care without evaluating a specific accommodation. Finally, we excluded studies set solely in subacute, residential, or nursing home settings to isolate access to health care activities as opposed to daily living and recreational activities. The inclusion and exclusion criteria were pilot tested and refined on 10 articles before being finalized (see Table 1 for full inclusion/exclusion criteria).

Table 1.

Scoping review inclusion and exclusion criteria.

Study characteristics	Inclusion criteria	Exclusion criteria
Timeframe	Publication year ≥ 2003
Intervention	Studies that evaluated or implemented accommodations facilitating communication access to a health care activity	Studies that did not specify evaluation of an accommodation that facilitated communication access to a health care activity in the research aims, methods, or outcomes Studies solely evaluating sign language interpreters
Participant population	Adult population (18 years and older) with a communication disability (includes any related health condition resulting in hearing, speech and language, voice, and/or cognitive disability)
Study design and publication type	Study designs that evaluated an accommodation or implementation of the accommodation intended for a health care setting (e.g., case study, efficacy, effectiveness, service evaluation, implementation study)	Studies that described the general state of health care for adults with communication disabilities, without specifying an accommodation being evaluated
		Review articles Study protocols, workshops, conference presentations or abstracts, textbook excerpts, or nonpublished work
		Letters to the editor, tutorials/didactic articles, and viewpoint articles
Settings	Inpatient acute care, inpatient acute rehabilitation, emergency department, outpatient clinic settings (primary or specialty care), or efficacy studies that identified the intended setting, health care communication activity being accessed, and the intended patient population	Residential or nursing home settings Studies focused on preservice training of health care professionals

Abstracts were screened against the inclusion criteria by two independent reviewers. Papers that met criteria underwent full-text review. Reasons for exclusion were recorded. Reviewers resolved disagreements through discussion at each stage of the selection process.

Stage 4: Charting the Data

Following completion of the full-text inclusion process, we arrived at the final set of studies from which data would be extracted. The primary author created the initial extraction form based on existing literature. This form was piloted and refined with the team across 15 studies and two iterations. The final extraction list and definitions can be found in Appendix B. Two reviewers independently extracted data on each included article. Discrepancies on extraction elements were resolved through team member discussion. To describe the general context of this work, we extracted the year and country in which studies were conducted.

For selection of accommodation type, reviewers selected a single accommodation from the initial list in addition to documenting a free-text description. When interventions shared components across multiple accommodation types, we deferred to the manuscript's characterization of the intervention. We created CD-related health condition groups based on the abstracts reviewed: aphasia and neurogenic, intellectual and developmental disabilities and autism, aphonia/dysphonia in critical conditions, dementia and cognitive impairment, hearing, traumatic brain injury, and any CDs (inclusive of CDs across conditions).

To understand how this work was being done, we extracted data on the health care setting, the health care workers involved, the type of evidence (efficacy, effectiveness, implementation/hybrid implementation, service evaluation, or case report; C. H. Brown et al., 2017), study design (randomized controlled trial, nonrandomized quasi experimental, descriptive/observational), and outcomes measured. To explore outcomes measured, reviewers documented free-text descriptions of study outcomes. We further classified outcomes as positive, neutral, or negative in experimental studies testing a hypothesis. For qualitative studies, we recorded major themes.

Stage 5: Collating, Summarizing, and Reporting

The coded data were retrieved from Covidence, exported to a Microsoft Excel file, and then imported into Stata (StataCorp, 2023) to calculate descriptive statistics on the number and proportions by extracted data elements. To arrive at finalized accommodation names and descriptions, the primary author reviewed extracted free-text descriptions sorted under each accommodation type and notes from team discussions. To describe outcome measures used, the primary author reviewed the free-text descriptions of outcomes generated by the reviewers. She also grouped quantitative measures used to assess patterns in measures used.

Results

We describe our methods following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Extension for Scoping Reviews Checklist (Tricco et al., 2018). We screened 1,614 record titles and abstracts published between January 2003 and August 1, 2024. After excluding duplicate records and studies that did not meet the inclusion criteria (see Table 1), 112 full-text reports remained. The research team screened the full-text reports using the same criteria and excluded another 54 studies. A total of 58 studies were included in this review (PRISMA diagram; see Figure 1; see Table 5 for a full list of all studies and their extraction elements).

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analysis diagram of evidence identified, screened, assessed for eligibility, and included in the review.

Table 5.

Full list of all studies and extraction data elements.

Author(s), year, country	Title	Intervention/accommodation	CD-related condition	Setting	Health care workers	No. of participants	Type of evidence and study design	Outcomes
Communication strategies
Armour et al., 2021, Australia	Supported Communication Video Training for the Nursing Department in an Inpatient Rehabilitation Hospital	Training for Supported Conversation for Aphasia (SCA) as a part of health care organizational training. SCA involved teaching health care providers how to interact with persons with aphasia.	Aphasia and neurogenic conditions	Inpatient rehabilitation provider training	Nurses and nursing assistants	2–50	Effectiveness, quasi-experimental	Positive, significant pre- to posttraining provider improvement on the Test of Knowledge of Aphasia by providers
Cameron et al., 2017, Australia	A Pre–Post Intervention Study Investigating the Confidence and Knowledge of Health Professionals Communicating With People With Aphasia in a Metropolitan Hospital	Communication partner training (CPT), which provides strategies to both persons with aphasia and their communication partners to support effective communication exchange	Aphasia and neurogenic conditions	Acute care	Allied health assistants; audiologists; case manager/social workers; dieticians; nurses; nursing assistants; OTs; pharmacists/allied health; PTs; audiology	51–100	Efficacy, quasi-experimental	Positive, significant improvement on mean provider confidence levels and identifying number of communication strategies used by providers. Measurement questionnaire was made by an investigator to assess confidence and knowledge of aphasia.
Hand et al., 2021, US	“They Looked at Me as a Person, Not Just a Diagnosis”: A Qualitative Study of Patient and Parent Satisfaction With a Specialized Primary Care Clinic for Autistic Adults	Use of written communication and visual prompts by providers in an autism specialty clinic	Intellectual and developmental disability/Autism	Primary care (autism specialty clinic)	Nurses; medical assistants; physicians/advanced practice providers	2–50	Service evaluation; descriptive	Qualitative, use of communication strategies like written communication helped to improve patient–provider communication
Hansen et al., 2022, Denmark	‘They Get the Opportunity to Say What Is Important for Them’: Exploring Staff's Early Perceptions of the Implementation of a New Communicative Approach to Patients With Aphasia	Training on and use of the KomHIT program and SCA. KomHIT included bot training providers on communication strategies and AAC pictures and easy-to-read texts.	Aphasia and neurogenic conditions	Inpatient rehabilitation	Nurses; nursing assistants; SLPs, OTs; PTs	2–50	Hybrid, descriptive	The qualitative, 6 months after training and use, program enhanced the involvement of patients with aphasia in their rehabilitation, and health care workers had an increased focus on communication. Barriers included time and goal setting.
Heard et al., 2017, Australia	Communication Partner Training for Health Care Professionals in an Inpatient Rehabilitation Setting: A Parallel Randomised Trial	E-Learning Plus (online communication partner training) compared with SCA	Aphasia and neurogenic conditions	Inpatient rehabilitation	Nurses; physicians/advanced practice providers; SLPs; OTs; PTs	51–100	Efficacy, randomized controlled trial	Positive, both programs had significant improvement in self-rating of provider confidence on a Likert scale created by investigators.
Horton, Clark, et al., 2016, UK	Methodological Issues in the Design and Evaluation of Supported Communication for Aphasia Training: A Cluster-Controlled Feasibility Study	Training on use of SCA	Aphasia and neurogenic conditions	Inpatient rehabilitation	Allied health assistants; nurses; SLPs; OTs; PTs	51–100	Hybrid, quasi-experimental	Neutral, insignificant differences on the patient measure Stroke and Aphasia Quality of Life Scale and the Communicative Access Measures for Stroke. Training cost per participant was estimated at £827. Small numbers limited the ability to obtain quality-adjusted life years.
Horton, Lane, & Shiggins, 2016, UK	Supporting Communication for People With Aphasia in Stroke Rehabilitation: Transfer of Training in a Multidisciplinary Stroke Team	Training on SCA	Aphasia and neurogenic conditions	Inpatient rehabilitation	Allied health assistants; nurses; SLPs; OTs; PTs; administrative staff	2–50	Implementation study of the context; descriptive	Qualitative, more fruitful staff–patient interactions. Severity of aphasia, cognitive impairments, and time constraints were barriers to implementing.
Jensen et al., 2015, Denmark	Implementation of Supported Conversation for Communication Between Nursing Staff and In-Hospital Patients With Aphasia	SCA use through champions, training with role play and group discussions, tools to support communication dialogue notebooks at bedside, delegation of responsibilities to staff	Aphasia and neurogenic conditions	Acute	Nurses, nurses' assistants; SLPs	2–50	Hybrid study; quasi-experimental	Positive; significant improvement by nurses as measured by the Knowledge of Aphasia Questionnaire. Communication seemed less frustrating for the patient. Higher frequencies of drawing, writing down words and use techniques. Qualitative, shortage of time, patient characteristics (e.g., patients being ill, not alert enough), other nursing demands like attending to more critically ill patients were barriers.
Kagan et al., 2024, Canada	Improving Communicative Access and Patient Experience in Acute Stroke Care: An Implementation Journey	Patient–provider communication programs	Aphasia and neurogenic conditions	Acute	Case manager/social workers; nurses; SLPs; OTs; pharmacists; PTs; other: recreation therapist, clinical team managers	2–50	Service evaluation; descriptive	Qualitative, key factors in sustaining change were motivation at an individual and organizational level, relational principles, adjustments related to capacity, resource support, buy-in from leadership, and staff at multiple levels.
Kistler et al., 2021, US	Evaluation of a Training Toolkit to Improve Clinicians' Skills for Dementia Advance Care Planning	Training toolkit for primary care clinicians aimed at improving patient/family–provider communication	Dementia/cognitive impairment	Primary care	Case manager/social workers; nurses; physicians/advanced practice providers	51–100	Implementation study; quasi-experimental	Positive, staff confidence significantly increased in determining capacity using the toolkit, as measured on an investigator-created survey based on advanced care planning communication training. Training increased documentation goals of care and decision-making discussions.
Murray et al., 2019, Australia	Impact of the Dementia Care in Hospitals Program on Acute Hospital Staff Satisfaction	Dementia Care in Hospitals Program Educational program designed to improve communication with patients with cognitive impairment. The program included systematic identification, use of an identifier above the patient's bedside to alert staff, and employment of a set of nine key communication strategies by all staff.	Dementia/cognitive impairment	Acute care	Allied health assistants; medical office staff; nurses; physicians/advanced practice providers; SLPs; OTs; PTs; nonclinical staff	> 100	Implementation; quasi-experimental	Positive; significant increase in provider confidence, comfort, and job satisfaction on an investigator-created survey developed with the Australian Institute for Primary Care, lit review, experts. Positive; staff perceived level of organizational support for caring for patients with cognitive impairment, assessed on the same survey were significantly improved.
Simmons-Mackie et al., 2007, Canada	Communicative Access and Decision Making for People With Aphasia: Implementing Sustainable Healthcare Systems Change	Use of SCA, translation of health materials into aphasia-friendly health materials, training, ward staff meeting, selection of facility-specific goals, and on-site support from SLP	Aphasia and neurogenic conditions	Multiple (acute care, rehab, long-term care)	Case manager/social workers; nurses; SLPs; OTs; PTs; social workers, community resource worker, allied health, nonclinical staff	2–50	Implementation, descriptive	Qualitative, increased knowledge of methods of supporting communicative access
Augmentative and alternative communication aids
Babbage et al., 2024, New Zealand	Inpatient Trial of a Tablet App for Communicating Brain Injury Rehabilitation Goals	Tablet app for communicating brain injury rehabilitation goals	Traumatic brain injury	Inpatient rehab	SLPs; OTs; PTs	2–50	Hybrid, descriptive	Frequency of video plays/engagement with videos by patients. Frequency of clinician updates on the app.
Berning et al., 2016, US	A Novel Picture Guide to Improve Spiritual Care and Reduce Anxiety in Mechanically Ventilated Adults in the Intensive Care Unit	Chaplain-led, picture-guided spiritual care	Aphonia/dysphonia in critical conditions	Spiritual care in the intensive care unit (ICU)	Chaplains/(allied health)	2–50	Effectiveness, descriptive	Positive, 100% of patients identified a spiritual affiliation, 47 (94%) identified one or more emotions, 45 (90%) rated their spiritual pain, and 36 (72%) selected a chaplain intervention. Time to complete consultation was 18 min.
Francis et al., 2021, Australia	The Use and Impact of a Supported Aphasia-Friendly Photo Menu Tool on iPads in the Inpatient Hospital Setting: A Pilot Study	Use of iPad containing picture menus	Aphasia and neurogenic conditions	Acute care, meal ordering	SLPAs	2–50	Hybrid, quasi-experimental	Neutral, no significant improvement in calories ordered and consumed by patients. But improvements in ease of and involvement with meal ordering. Time spent ordering the meal was 13.74 min with the AAC method vs. 9.29 with the usual menu.
Gropp et al., 2019, South Africa	Nurses' Perspectives About Communication With Patients in an Intensive Care Setting Using a Communication Board: A Pilot Study	Vidatak EZ Board with basic need pictures (1-hr training provided on use of the board)	Aphonia/dysphonia in critical conditions	ICU	Nurses	2–50	Hybrid, quasi-experimental	Positive, increased use of communication boards by providers. However, this increase was not sustained 2 weeks after training.
Handberg & Voss, 2018, Denmark	Implementing Augmentative and Alternative Communication in Critical Care Settings: Perspectives of Healthcare Professionals	Multiple AAC devices: (a) iPad app: GoTalkNow; (b) Windows app: On Screen Communicator; (c) letter board; (d) eye-tracking board; (e) pain scale; (f) auditive partner-assisted board; (g) eye-tracking letter board	Aphonia/dysphonia in critical conditions	ICU	Nurses; OTs; PTs	2–50	Service evaluation, descriptive	Qualitative, professionals highly motivated and endorsed that AAC could help and save them time
Happ et al., 2004, US	Electronic Voice-Output Communication Aids for Temporarily Nonspeaking Patients in a Medical Intensive Care Unit: A Feasibility Study	Voice output communication aids (VOCAs)	Aphonia/dysphonia in critical conditions	ICU	Nurses; allied health (respiratory therapist)	2–50	Hybrid, quasi-experimental	Positive, patients who used the device reported significantly less difficulty with communication after device use as measured on the Ease of Communication Scale. Qualitative, contextual barriers were device positioning, fluctuation in patient cognitive and motor status, staff time constraints, staff lack of familiarity with the device, and device complexity.
Hurtig et al., 2019, US	Improving Patient Safety and Patient–Provider Communication	Voxello noddle switch and noddle chat tablet	Aphonia/dysphonia in critical conditions	ICU	Nurses	> 100	Hybrid, quasi-experimental	Positive, significant difference between the noddle and no-access patient groups related to ease of summoning help and communicating effectively as measured on investigator created survey. Positive perceptions of patient's ability to summon nurses and communicate effectively by nurses.
Koszalinski et al., 2020, Scotland	The Use of Communication Technology to Affect Patient Outcomes in the Intensive Care Unit	Speak for Myself-Voice Tablet (SFM-V)	Aphonia/dysphonia in critical conditions	ICU	Nurses		Effectiveness, quasi-experimental	Positive, statistically reduced patient-reported symptoms of depression and reduction of anxiety on the Hospital Anxiety and Depression scale. SFM-V was not effective for some patients in ICU (e.g., difficulty manipulation tablet, patients with aphasia).
Kuo et al., 2023, Taiwan	The Usability of an AAC Pain Description System for Patients With Acquired Expressive Communication Disorders	AAC Pain Description System on a Mobile App	Aphasia and neurogenic conditions	Acute care, post neurosurgical ward	Nurses	2–50	Effectiveness, quasi-experimental	Positive, patients were satisfied with the app using investigator created survey on usability and satisfaction with the PainDiary app. Time to collect headache pain was less using the PainDiary app.
Maringelli et al., 2013, Italy	Gaze-Controlled, Computer-Assisted Communication in Intensive Care Unit: “Speaking Through the Eyes”	Eye gaze communication system	Aphonia/dysphonia in critical conditions	ICU	Nurses; physicians/advanced practice providers	2–50	Effectiveness, quasi-experimental design	Positive, patients adapted to gaze-controlled communication system within 15 min. Positive, improvement in Likert scale responses to ability to understand patient, decide on therapy, communicate with patient's family on investigator developed survey for patients.
Muthuswamy et al., 2014, UK	Utility of Optical Facial Feature and Arm Movement Tracking Systems to Enable Text Communication in Critically Ill Patients Who Cannot Otherwise Communicate	Movement tracking system (facial feature tracking and arm movement)	Aphonia/dysphonia in critical conditions	ICU	None	2–50	Efficacy, quasi-experimental	Positive, average speed of sentence formation was 81 s (range: 58–120) and 104 s (range: 60–160) for facial feature and arm tracking systems, respectively (p < .001, 2-tailed independent-samples t test)
Rodriguez et al., 2012, US	Development of a Communication Intervention to Assist Hospitalized Suddenly Speechless Patients	Programmable speech-generating device	Aphonia/dysphonia in critical conditions	Multiple (ICU and acute)	Ward clerks	2–50	Hybrid; descriptive	Positive, 95% of messages were understood by ward clerks on usability of Communication Intervention/Accommodation Form. Device was accessible to the participants within arm's reach 52% of the time.
Customized plans—created by provider
D'Souza, Godecke, et al., 2022, Australia	Investigation of the Implementation of a Communication Enhanced Environment Model on an Acute/Slow Stream Rehabilitation and a Rehabilitation Ward: A Before-and-After Pilot Study	Communication enhanced environment model: SLP assessed and recommended accommodations for each patient, training on use of communication partner strategies, posters specifying individualized communication strategies, “communication support packs” of aids (e.g., whiteboards, AAC aids)	Aphasia and neurogenic conditions	Multiple (acute care and inpatient rehabilitation)	Nurses; SLPs; allied health, nonclinical staff	2–50	Hybrid, quasi-experimental	Neutral, no significant difference in language activity level by patients. Fidelity and feasibility of the intervention—71% of the model was available to the intervention group.
D'Souza, Ciccone, et al., 2022, Australia	Staff and Volunteers' Perceptions of a Communication Enhanced Environment Model in an Acute/Slow Stream Rehabilitation and a Rehabilitation Hospital Ward: A Qualitative Description Study Within a Before-and-After Pilot Study	Communication enhanced environment model as above	Aphasia and neurogenic conditions	Multiple (acute care and Inpatient rehabilitation)	Case manager/social workers; nurses; SLPs; OTAs; PTs; volunteers	2–50	Hybrid, descriptive	Qualitative, factors that impacted implementation were multilevel at the hospital, staff, and patient.
Happ et al., 2010, US	SPEACS-2: Intensive Care Unit “Communication Rounds” With Speech Language Pathology	Individualized communication plan created by SLPs, inclusive of low- and high-tech AAC, provider-led communication strategies. Communication resource nurses served as champions on each unit. Teaching posters on the “Communication Strategy of the Week.” A communication cart of tools. An SLP led a weekly communication case conference to dissemination patients' communication strategies with staff.	Aphonia/dysphonia in critical conditions	ICU	Nurses	1	Case report	n/a
Happ et al., 2014, US	Effect of a Multi-Level Intervention on Nurse–Patient Communication in the Intensive Care Unit: Results of the SPEACS Trial	Individually tailored plans created by SLPs that specified type of AAC devices and communication strategies. Communication cart of tools. SLP leads a weekly communication case conference.	Aphonia/dysphonia in critical conditions	ICU	Nurses	51–100	Hybrid, quasi-experimental	Positive, patient communication frequency (mean number of communication acts within a communication exchange) and patient-centered nurse communication behaviors increased significantly in one ICU.
Maxwell et al., 2021, Ireland	Using a Multidisciplinary Approach to Reveal Decision-Making Capacity Within Acute Care for an Individual With Aphasia	SLP designed communication strategies and use of an adapted version of a capacity evaluation (CACE) to assess decision-making for a patient with aphasia.	Aphasia and neurogenic conditions	Acute care	Nurses; physicians/advanced practice providers; SLPs; OTs	1	Case report	n/a
Radtke et al., 2011, US	Listening to the Voiceless Patient: Case Reports in Assisted Communication in the Intensive Care Unit	SLPs created a list of appropriate accommodations for nursing staff and family to follow. Accommodations were a combination of low tech, high tech AAC, and partner-led communication strategies.	Aphonia/dysphonia in critical conditions	ICU	Nurses, SLP	1	Case report	n/a
Trotta et al., 2020, US	Improving Nonvocal Critical Care Patients' Ease of Communication Using a Modified SPEACS-2 Program	Nurse assessment of needed accommodations with SLP consultation as needed. Plans composed of low-tech and high-tech AAC. Implementation strategies: Decision-making algorithm for nurses, training, pocket reference guides, instructional manual, aids in a “communication cart”	Aphonia/dysphonia in critical conditions	ICU	Nurses	> 100	Hybrid; nonrandomized, quasi-experimental	Positive, patient's Ease of Communication Scale scores improved significantly. Nurses' use of communication techniques and compliance with communication plans of care increased after training Frequency of documentation of communication techniques improved post intervention.
Customized plans—created by patient
Grant et al., 2024, UK	“I Am Afraid of Being Treated Badly If I Show It”: A Cross-Sectional Study of Healthcare Accessibility and Autism Health Passports Among UK Autistic Adults	Autism Health Passports: a range of communication tools that aim to provide information about health care needs in a standardized way.	Intellectual and Developmental Disabilities and Autism	Any	N/A	≥ 100	Service evaluation, descriptive	Descriptive, 1.5% of respondents with autism used a health passport at least half the time on investigator created survey. Qualitative. Passports sound good in theory, but the barrier is that they are not well integrated into health care delivery.
Heifetz & Lunsky, 2018, Canada	Implementation and Evaluation of Health Passport Communication Tools in Emergency Departments	Health passport communication tools providing information about the individual, their likes and dislikes, how the individual communicates (e.g., verbal/nonverbal, communication device use), medical history, current medication, supports needed	Intellectual and Developmental Disabilities and Autism	Multiple (acute care, outpatient primary and specialty clinics)	Nurses, hospital clinical staff, community health and IDD service providers	0–50	Hybrid, descriptive	Qualitative, The tool makes the patient more comfortable. Implementation factors were time needed to engage, the tool was not consistently used, low awareness of the tool.
Kang et al., 2022, Australia	A Trial of the AASPIRE Healthcare Toolkit With Australian Adults on the Autism Spectrum	Online health care toolkit AASPIRE includes basic health information, rights, diagnosis, and accommodation needs.	Intellectual and Developmental Disabilities and Autism	Primary care	Physicians, allied health (psychologist, psychiatrist, dieticians)	0–50	Implementation – context evaluation, descriptive	Qualitative. The toolkit provided structure to appointments, supplemented new knowledge, and increased confidence; however, it was lengthy. Best for new visits.
Nicolaidis et al., 2016, US	The Development and Evaluation of an Online Healthcare Toolkit for Autistic Adults and Their Primary Care Providers	AASPIRE Healthcare toolkit including the Autism Healthcare Accommodations Tool (AHAT)—patients to create a personalized accommodations report to bring to appointment	Intellectual and Developmental Disabilities and Autism	Primary care	Physicians/advanced practice providers	≥ 100	Effectiveness, quasi-experimental	Positive. Health care self-efficacy increased, and satisfaction with communication improved on investigator-created survey. Qualitative. Toolkit helped clarify patient needs, enabled them to self-advocate. Providers found the tool useful.
Parke et al., 2019, Canada	Know Me—A New Person-Centered Approach for Dementia-Friendly Emergency Department Care	Hospital readiness tools that described the patient's health and communication needs	Dementia/cognitive impairment	Emergency department	n/a	0–50	Efficacy, descriptive	Qualitative, caregivers perceived that the tool could decrease responsive behaviors in the ED, skepticism that the tool would be used by ED nurses
Turk et al., 2010, UK	An Evaluation of the Implementation of Hand Held Health Records With Adults With Learning Disabilities: A Cluster Randomized Controlled Trial	Handheld health record: a 50-page binder containing patient's individualized health information including communication needs	Intellectual and developmental disabilities and Autism	Primary care	Physicians/advanced practice providers	≥ 100	Hybrid; randomized controlled trial	Neutral. Slightly greater but not significant increase in attendance at primary care visit as compared with control. 63% of patients with IDD & 55% of carers adopted the handheld record.
Learning disability nurse
M. Brown et al., 2012, Scotland	Learning Disability Liaison Nursing Services in South-East Scotland: A Mixed-Methods Impact and Outcome Study	Description of Learning Disability Liaison Nursing (LDLN) service	Intellectual and developmental disability and Autism	Acute care	Nurses; physicians/advanced practice providers	51–100	Service evaluation; descriptive	Descriptive, 30% of patients received nursing service of “communication advice” Proportion of referrals by clinical area were provided Qualitative, LDLN helped with coordinating care, promoting successful communication. Variation by region in types of providers referring to LDLN, type of hospital admission, reasons for referral
Clarke et al., 2023, UK	Person-Centred Critical Care for a Person With Learning Disability and COVID-19: Case Study of Positive Risk Taking	Description of LDLN	Intellectual and developmental disability and Autism	Acute care	Dieticians; nurses; SLPs; OTs; pharmacists; PTs; other: psychologist	1	Case report	N/A
Castles et al., 2014, UK	Experiences of the Implementation of a Learning Disability Nursing Liaison Service Within an Acute Hospital Setting: A Service Evaluation	Learning disability nurse services described as assisting with discharge planning, translating medical information into plain language, reasonable adjustments	Intellectual and developmental disability and Autism	Acute care	Allied health assistants; case manager/social workers; nurses; PTs; nonclinical staff	> 100	Service evaluation; descriptive	Qualitative, patients and providers reported that learning disability nurses facilitated patient–provider communication
Jackson & Read, 2008, UK	Providing Appropriate Health Care to People With Learning Disabilities	Learning disability nurse	Intellectual and developmental disability and Autism	Acute care	Nurses	1	Case report	N/A
MacArthur et al., 2015, UK	Making Reasonable and Achievable Adjustments: The Contributions of Learning Disability Liaison Nurses in ‘Getting It Right’ for People With Learning Disabilities Receiving General Hospitals Care	LDLN have specialist expertise to identify reasonable adjustments. Reasonable adjustments include altering physical environments, providing auxiliary aids, adjusting policies/procedures and providing emotional and behavioral support.	Intellectual and developmental disability and Autism	Acute care	Nurses, nonclinical ward staff	2–50	Service evaluation; descriptive	Descriptive. Proportion of patients with whom the LDLN conducted specific activities related to reasonable adjustments. Qualitative, LDLNs' role involved implementing practical adjustments, providing access to information and modifying care.
Ní Riain & Wickham, 2024, Ireland	“She Just Makes It Easier … ” The Impact of Having a Dedicated Nursing Role in Supporting People With Intellectual Disability When Accessing Acute Hospitals, From the Perspective of Their Support Staff, the Irish Context	Describes the LDLN service—see outcomes	Intellectual and developmental disability and Autism	Acute care	Nurses	2–50	Service evaluation; descriptive	Qualitative. Themes described the role of the learning disability nurse, such as improving engagement during admission, being a conduit of information through improved communication and making information understandable, and improving experience of people with intellectual disability.
Rees & Northway, 2022, UK	Access to Secondary Healthcare for People With Intellectual Disabilities: The Role of Community Learning Disability Nurses in Wales	LDLN service: promote positive health care experiences for persons with an intellectual disability. They provide expert knowledge and skills to support acute health care staff, and ensuring that reasonable adjustments/accommodations are in place—see outcomes.	Intellectual and developmental disability and Autism	Acute care	Nurses	2–50	Service evaluation; descriptive	Qualitative. The LDNs individualized accommodations to the patients using a combination of a hospital passport, adapted written health information, and care coordination.
Adapted written health materials
Carling-Rowland et al., 2014, Canada	Increasing Access to Fair Capacity Evaluation for Discharge Decision-Making for People With Aphasia: A Randomised Controlled Trial	Communication Aid to Capacity Evaluation (CACE), an easy read and picture version of a standardized capacity assessment	Aphasia and neurogenic conditions	Outpatient, for admission to long-term care facility	Social workers/case managers	51–100	Efficacy, randomized controlled trial	Positive, significantly increased patient ability to convey information and decreased frustration on a Likert scale created by the investigator. No difference in comprehension. Providers had increased ability to determine capacity.
Chinn, 2020, UK	An Empirical Examination of the Use of Easy Read Health Information in Health Consultations Involving Patients With Intellectual Disabilities	Easy Read health information (ERHI)—adapted written resources typically using short sentences, jargon‐free language, and verbal text supported or explicated through visual images	Intellectual and Developmental Disabilities and Autism	Primary care	Primary care physicians, specialized disability nurses	2–50	Hybrid, descriptive	Qualitative. Patients found the easy-read information acceptable. 22% of providers adopted ERHI.
Rose et al., 2003, Australia	The Effectiveness of Aphasia-Friendly Principles for Printed Health Education Materials for People With Aphasia Following Stroke	Aphasia-friendly health materials (less words per sentence, and more graphics)	Aphasia and neurogenic conditions	n/a	None	2–50	Efficacy, quasi-experimental	Positive. Patients comprehended 11.2% more information from materials with an aphasia friendly format on investigator created knowledge test. However, a third of patients preferred the existing brochures.
Systematic Identification of communication disability and/or accommodation need
Buning et al., 2024, US	Self-Reported Accommodation Needs for Patients With Disabilities in Primary Care	All patients presenting for a wellness visit were given a questionnaire querying accommodation needs	Any disabilities	Primary care	Medical office staff	> 100	Effectiveness; descriptive	4.6% of patients reported hearing-related disabilities using the question and process. The top requested accommodations were communication and cognitive-based supports like inclusion of a support person with care decisions.
Fox et al., 2023, Australia	The Impact of a Cognitive Impairment Support Program on Patients in an Acute Care Setting: A Pre-Test Post-Test Intervention Study	1. Identification of patients with cognitive impairments admitted to the hospital with a cognitive impairment identifier 2. Educational program on communication techniques to providers when speaking with persons with cognitive impairment	Dementia/cognitive impairment	Acute	Nurses; physicians/advanced practice providers; other: allied health, administration and operational staff including cleaners, security, food services staff		Hybrid, quasi-experimental	Neutral. Insignificant reduction in admissions Patient improvements on two Dementia Quality of Life Measure domains Statistically significant improvement in clinical staff confidence to care for patients with cognitive impairment (p = .003), satisfaction with organizational support for patients (p = .004), and job satisfaction (p ≤ .001)
Morris et al., 2021, US	Implementation of Collection of Patients' Disability Status by Centralized Scheduling	Asking about disability status including CD during new patient registration by centralized call center staff implementation strategy: training, visual reminders (table tents) with the prompt, and question sets	Any disabilities	Primary care	Registration staff agents		Implementation; quasi-experimental	Positive. Increase in completion rates from baseline (9.5%) to maintenance (53.5%). 1.6% of patients asked why data were being collected. Patients were comfortable disclosing disability status. Agents preferred asking the screener question rather than the long set.
Mudrick et al., 2020, US	Can Disability Accommodation Needs Stored in Electronic Health Records Help Providers Prepare for Patient Visits? A Qualitative Study	Accommodation needs fields were integrated into the electronic health record	Any disabilities	Primary care	Case manager/social workers; medical office staff; nurses; nursing assistants; physicians/advanced practice providers; other: psychologist, community health worker		Service evaluation; descriptive	Qualitative. Theme 1: Accommodation needs generally are not known in advance of the patient's visit. Theme 2: EHR systems offer helpful information, but with usage challenges and information gaps. Theme 3: Accommodations do occur at health visits but are often developed at the time of the visit. Theme 4: Knowledge of a regular patient is often the basis for advanced accommodation preparation. Theme 5: Providers acknowledge the benefit of preparation for accommodation needs and are supportive of methods to enable it.
Varadaraj et al., 2022, US	Identifying Accessibility Requests for Patients With Disabilities Through an Electronic Health Record–Based Questionnaire	“Do you have any accessibility requests for this visit?” was asked of all new patients making appointments.	Any communication and other disabilities	Eye clinic	Call center and front-desk staff		Service evaluation; descriptive	9.4% of patients made an accessibility request of the clinic
Patient–Family Agenda tool
Smith et al., 2022, Canada	Perceived Barriers and Facilitators of Implementing a Multicomponent Intervention/Accommodation to Improve Communication With Older Adults With and Without Dementia (SHARING Choices) in Primary Care: A Qualitative Study	A multicomponent intervention that integrates simple communication strategies that have been demonstrated to be effective including a checklist for person–family agenda setting, based on the Wolff studies below	Dementia/cognitive impairment	Primary care	Nonclinical (medical office staff); physicians/advanced practice providers	1–50	Implementation; descriptive	Qualitative. Primary care clinicians, staff, and patients and families felt the checklist was acceptable, had a strong evidence base, and improved readiness for the advanced care visit. Barriers included the complexity of the intervention, costs, and time.
Wolff et al., 2018, US	Patient–Family Agenda Setting for Primary Care Patients With Cognitive Impairment: The SAME Page Trial	Previsit checklist/agenda setting and role specification of partner to support primary care visit	Dementia/cognitive impairment	Primary care	Physicians/advanced practice provider		Effectiveness, randomized controlled trial	Positive. Communication between provider and patient was significantly more patient centered in the intervention dyads, measured by the Roter Interaction Analysis System (RIAS). No effect on visit duration.
Wolff et al., 2021, US	SHARING Choices: A Pilot Study to Engage Family in Advance Care Planning of Older Adults With and Without Cognitive Impairment in the Primary Care Context	Person–family agenda-setting checklist to align patient and family perspectives regarding the role of the family member in primary care interactions, part of a larger, multicomponent intervention	Dementia/cognitive impairment	Primary care	Physicians/advanced practice provider		Hybrid; nonrandomized quasi-experimental pilot	Positive, 75% of patients identified with cognitive impairment completed advanced care planning conversations. Uptake of each therapeutic component was roughly 60%.
Hearing amplifier
Chodosh et al., 2021, US	The HEAR-VA Pilot Study: Hearing Assistance Provided to Older Adults in the Emergency Department	Pocket talkers, a simple hearing assistance device	Hearing	Emergency department (ED)	Research assistants trained on using the personal amplifier, ED staff	> 100	Effectiveness, randomized controlled trial	Positive, 75% of intervention subjects could understand ED instructions without effort as compared to 56% for controls using the Hearing and Understanding Questionnaire. ED revisits—3% of subjects vs. 9.0% in controls
Voice amplifier
Wong et al., 2021, US	Randomized Controlled Trial of a Novel Communication Device Assessed During Noninvasive Ventilation Therapy	Noninvasive voice amplifier attached to an orofacial mask made for intubated patients	Aphonia/dysphonia in critical conditions	Intensive care unit	None	0–50	Efficacy, randomized controlled trial	Positive. Patient word and sentence intelligibility using the voice amplifier was increased relative to the control group (35% vs. 61%).
Virtual visits
Selick et al., 2023, Canada	“Can You Hear Me Now?”: A Qualitative Exploration of Communication Quality in Virtual Primary Care Encounters for Patients With Intellectual and Developmental Disabilities	Virtual primary care encounters	Intellectual and developmental disabilities and Autism	Primary care	Physicians/advanced practice providers; nonclinical (IDD support staff)	0–50	Service evaluation, descriptive	Qualitative. Patients were able to participate and communicate in health care from a space they felt comfortable. Technical challenges were also present, and some elements of communication were hindered.

Note. CD = communication disability; US = United States; UK = United Kingdom; AAC = augmentative and alternative communication; SLPs = speech-language pathologists; SLPAs = speech-language pathology assistants; OTs = occupational therapists; n/a = not applicable; PTs = physical therapists; IDD = Intellectual and developmental disabilities; AASPIRE = Academic Autism Spectrum Partnership in Research and Education.

Roughly a third of the studies were conducted in the United States (34%), the United Kingdom or Europe (31%), followed by Australia (17%; see Table 2). The number of studies published steadily increased across the 10.5-year period. There was a range of zero to two studies occurring in the first decade and two to nine studies occurring in the last decade, with an overall median of two studies conducted annually. Sample sizes were typically small, with two thirds involving 50 or fewer participants (66%).

Table 2.

Characteristics of studies included in review.

Study characteristic	n (%)	Study characteristic	n (%)
Country where the study was conducted		Health care worker type, by study
United States	20 (34)	Nurses, nursing and medical assistants	37 (32)
United Kingdom and Europe	18 (31)	Physicians/advanced practice providers	17 (15)
Australia	10 (17)	SLPs or SLPAs	14 (12)
Canada	7 (12)	Allied health	13 (11)
South Africa/Taiwan/New Zealand	3 (6)	Nonclinical staff (e.g., security, volunteers)	13 (11)
Total	58	OTs/OTAs/PT/PTAs	13 (11)
No. of participants		Case manager/social workers	8 (7)
Case report	5 (9)	Audiologists	1 (1)
2–50	33 (57)	Totala	116
51–100	9 (16)	Type of evidence
> 100	11 (19)	Hybrid/implementation component	25 (43)
Total	58	Service evaluation/quality improvement	12 (21)
Communication disability–related health condition		Intervention effectiveness only	9 (16)
Aphasia and neurogenic conditions	16 (28)	Intervention efficacya	7 (12)
Intellectual and developmental	15 (26)	Case report	5 (9)
Disabilities, autism		Total	58
Aphonia/dysphonia in critical conditions	14 (24)	Study design
Dementia/cognitive impairment	7 (12)	Descriptive/observational	30 (52)
Any communication disabilities	4 (7)	Nonrandomized, quasi-experimental	22 (38)
Hearing	1 (2)	Randomized controlled trial	6 (10)
Traumatic brain injury	1 (2)	Total	58
Total	58	Outcome direction b
Health care setting		Positive	24 (86)
Inpatient Acute (noncritical) care	14 (24)	Neutral	4 (14)
Outpatient (primary care)	13 (22)	Total	28
Intensive care unit	11 (19)
None (efficacy)	7 (12)
Acute rehabilitation	6 (10)
Multiple	6 (9)
Emergency department	1 (2)
Outpatient (specialty)	1 (2)
Total	58

Note. SLPs = speech-language pathologists; SLPAs = speech-language pathology assistants; OTs = occupational therapists; OTAs = occupational therapy assistants; PTs = physical therapists; PTAs = physical therapy assistants.

^aThe total was greater than 58 as studies involved multiple health care worker types or outcomes.

^bOf the quasi-experimental and randomized controlled trials.

Research Question 1: What Communication Accommodations Have Been Studied and for Which CD-Related Health Conditions?

We identified and described 10 accommodations investigated in the 58 included studies (see Table 3). Descriptions of each accommodation varied across studies within accommodation type. For instance, some communication strategies accommodations included AAC aids (e.g., the KomHit program [Hansen et al., 2022]), while others did not (e.g., Armour et al., 2021). Another example is across learning disability nurses, there was variability in what communication-related services provided. Consistently these accommodations were complex with multiple parts and variable forms (Hawe et al., 2004). To further classify these accommodations into conceptually distinct categories, we drew upon the complex intervention literature (Hawe et al., 2004; Jolles et al., 2019). We derived a higher order level of categorization called accommodation “functions.” Accommodation functions are the change mechanisms being targeted by the accommodation (e.g., augment patient communication or adapt provider communication), which can take on flexible forms depending on local contexts (Hawe et al., 2004; Jolles et al., 2019). For example, AAC aids, hearing amplifier, and voice amplifier were all included under the function of “Augment patient communication,” and the Communication strategies accommodation type was categorized under the function of Adapt provider communication. Table 3 lays out these functions organized by socioecologic level (patient/family, provider, health care organization/clinic).

Table 3.

Accommodations and descriptions organized by their function and socioecological level targeted.

Socioecologic level targeted	Function		Accommodations	Description based on studies reviewed
Patient	Augment patient communication		Augmentative and alternative communication aids (AAC aids)	Use of picture, symbol, word boards, or assistive technology to support communication. Examples included the Noddle switch and chat tablet by Voxello for patients on mechanical ventilation (Hurtig et al., 2019) and iPad with picture menus for patients with aphasia (Francis et al., 2021)
			Hearing amplifier	A device that amplifies incoming speech to the wearer to support hearing and reception (e.g., Chodosh et al., 2021)
			Voice amplifier	A device worn by the speaker to increase their volume to support vocal expression (e.g., Wong et al., 2021)
	Integrate family support		Patient–Family Agenda Tool	A checklist completed by patients and care partners prior to the appointment, to specify the communication role of the care partner in the medical appointment and the patient's medical agenda. The Patient–Family Agenda Tool prompt was “How can your family member or friend be most helpful today?”. Example options included: “Listen to what the doctor says and take notes,” or “Help you understand what the doctor says or means” (Wolff et al., 2021)
Provider	Adapt provider communication		Communication strategies	Providers employing strategies such as slowing down, providing options, asking yes/no questions, writing key words. For example, the KomHit program (Hansen et al., 2022).
Clinic or health care organization	Infrastructural capacity and supports for communication access	Identify patients with communication disabilities, tailor, and convey accommodation needs to health care team.	Systematic identification of CD and needs	Systematic, routine identification of accommodation needs by a clinic or health system as a first step leading to provision of accommodations. For example, registration staff screening and documenting all new patients using the question, “Due to a disability, do you need any additional assistance or accommodations during your visit?” (Morris et al., 2021)
			Customized plan	Specifies accommodation needs, individualized to the patient. It is created by a skilled provider or the patient, for health care team members to read and implement. For example, in the AASPIRE Healthcare toolkit, patients created a personalized accommodations report for their providers (Nicolaidis et al., 2016).
		Modify policies and processes of health care delivery affecting communication	Adapted written health materials	Written health materials provided by the clinician/organization that were modified to increase accessibility for communication disability populations. For example, one study developed the Communication Aid to Capacity Evaluation (CACE), a pictorial + simplified wording format version of a standardized capacity evaluation, for persons with aphasia (Carling-Rowland et al., 2014).
			Virtual visit	A health care visit conducted virtually (e.g., Selick et al., 2023)
		Both	Learning disability nurse	Learning disability nurses (LDNs) specialize in caring for people with intellectual and developmental delays. They serve as an advocate, navigator, coordinator of accommodations and care modifications and mediator of complex medical communication to patients (e.g., Castles et al., 2014). In all studies included, they practiced in the United Kingdom or Europe.

Note. CD = communication disability.

Across the 10 accommodations, the three most frequently examined were customized plans (22%), communication strategies (21%), and AAC aids (21%). Across accommodations, aphasia and neurogenic conditions, intellectual and developmental disabilities and autism, and critical care–related voice disorders were the most prevalent populations targered. Within aphasia and neurogenic conditions, almost all (15 of the 16 studies) addressed aphasia exclusively. Table 4 displays a heat map of the number of studies conducted by accommodation and the population targeted. Most accommodations were studied in one to three CD-related conditions, with the exception of systematic identification of CDs, which was studied agnostic to CD-related condition.

Table 4.

Heat map of number of studies conducted by accommodation type and health condition.

Research Question 2: How Have Accommodations Been Studied? Health Care Settings, Health Care Workers Involved, Methods and Outcomes

Studies most often took place in inpatient noncritical care (24%; the accommodation most often studied within inpatient noncritical care was learning disability nurse), outpatient primary care (22%; diverse accommodations), and intensive care unit settings (19%; accommodations were most often AAC aids; see Table 2). Diverse health care worker types across clinical and nonclinical roles (e.g., registration staff and security guards), took part in providing accommodations. Nurses and nursing assistants most often provided or implemented accommodations (32% of all providers involved). SLPs were involved in providing or implementing the accommodation in 14 studies (12%) and audiologists in one (1%). Studies in which SLPs or audiologists were involved addressed communication strategies (n = 9), customized plan (n = 3), AAC aids (n = 2) and learning disability nurse (n = 1).

Research Methods

Table 2 lists the distribution of study design, evidence type, and outcomes measured. Most studies were descriptive/observational (43%). The most common evidence type was an implementation or hybrid approach (43%), followed by evaluations of services or quality improvement programs (21%).

Outcomes

Of the 58 studies, 38 included quantitative outcome measures and 20 reported qualitative outcomes (see Table 5). Quantitative outcome measures were heterogeneous. The only common outcome measures were the Ease of Communication Access Measure (Happ et al., 2004; Trotta et al., 2020) and the Test of Knowledge of Aphasia (Armour et al., 2021; Heard et al., 2017); each used in two studies each. Most measures were investigator created, between six and 39 items in length, and measured concepts of communication access, feasibility, or usability of the accommodation. Although rigorously synthesizing findings was beyond the scope of this review, of studies testing a hypothesis (quasi-experimental and randomized controlled trial studies, 28 studies), 86% had findings in a positive direction. The remaining 14% of studies had neutral findings.

Discussion

In this scoping review of communication accommodations studied, we found a small but growing number of studies published between 2003 and 2024. We identified 10 accommodations addressing five communication functions within a health care communication exchange. The populations addressed most often were aphasia and related neurologic conditions, intellectual and developmental disabilities and autism, and aphonia/dysphonia in critical conditions. Investigations were typically conducted in the context of real-world health care, employed descriptive or quasi-experimental designs, and addressed research questions of implementation. Findings were often positive, but outcome measures were heterogeneous. Finally, SLPs were infrequently a part of implementing accommodations in this body of evidence. In this discussion, we examine findings in the context of disability policy, practice, and related literature to advance the science in this area of health equity work.

Communication Accommodations Studied

Conceptual clarity in defining accommodations is needed to interpret results and compare findings across investigations (Proctor et al., 2013). This study identified 10 tangible accommodations and their higher level intents (functions) within the context of supporting health care communication for people with CDs. These accommodations and functions can be used in practice and research. In practice, having a concrete list of accommodations with basic definitions is useful for health care organizations and providers wanting to fulfill their legal mandates (Oshita et al., 2024). For research purposes, having a higher level, conceptually distinct schema of functions (e.g., adapt provider communication) is useful for measurement as it enables a basis for comparing and synthesizing findings across variable, locally defined accommodations.

The communication accommodations identified in these findings are not aligned with the example accommodations outlined in policy documents. The federal example list primarily targets the hearing population and the function of augmenting patient communication (U.S. Department of Justice Civil Rights Division, 2020). In contrast, studied accommodations support a broader range of populations and functions. This highlights an opportunity for future policy guidance to include example accommodations supporting a wider range of CD populations.

CD Populations Studied

Study populations were typically defined by single health conditions (e.g., dementia, intellectual, and developmental disability and autism). This approach may limit generalizability across the CD population. Patients across CD populations may have similar communication needs and benefit from the same accommodations. A study using an expanded population across CD populations was D'Souza, Godecke, et al. (2022) which examined a customized plans accommodation. This was the only study in the “Aphasia and Neurogenic conditions” group which expanded their study population beyond aphasia, to other neurogenic conditions. One possible alternative is including study populations by their functional need rather than a health condition. This has precedence in the health-related social needs literature where social care interventions and populations studied are classified by social need such as patients experiencing food insecurity or unstable housing (Gottlieb et al., 2017; Krahn et al., 2006).

How Accommodations Are Studied

Studies on communication accommodations in health care were typically descriptive in nature and utilized heterogeneous outcome measures. This is similar to the social care interventions literature, which like the accommodations literature, targets non-medical interventions supporting health and health care access. This literature has been characterized as primarily descriptive and utilizing heterogeneous outcome measures (Gottlieb et al., 2017). Gottlieb and authors attribute this state to challenges in outcome measurement and documentation of the population of interest within health care organizations, in their case, patients with unmet health-related social needs. Applying this lesson to accommodation studies brings to surface systematic identification of CDs and needs, one of the 10 accommodations identified in this study. Systematic identification of CDs and needs in health care settings would enable trials in real-world settings and support homogeneity in outcomes through linkage of CD status, accommodations provided, and routine outcomes captured in the electronic health record.

There were few effectiveness and many descriptive hybrid and implementation studies in this body of work. This reversal of the traditional research pipeline appears appropriate in the context of federal policy supporting equitable communication access in health care as a civil right, and provision of accommodations as a part of this access Additionally, entities are required to give primary consideration to people with CDs in determining the need for and type of accommodation (U.S. Department of Justice Civil Rights Division, 2020). In this context, research endeavors on accommodations should prioritize implementation of accommodations in health care settings for widespread adoption, before or simultaneous to studies on effectiveness. Waiting to prove effectiveness of accommodations should not preclude studying their implementation.

The Role of SLPs

SLPs have arguably the most content expertise of all health care professionals to guide and support accommodations at patient, provider, and health care organizational levels. However, SLPs infrequently took part in studies on communication accommodations. Supporting communication access is included under the ASHA SLP scope of “Population and Systems” (American Speech-Language-Hearing Association, 2016), which states that SLPs have a role in “(a) managing populations to improve overall health and education,” and includes examples such as “use plain language to facilitate clear communication for improved health and educationally relevant outcomes; collaborate with other professionals about improving communication with individuals who have communication challenges; … analyzing and improving communication environments.” Examples of SLP involvement include the following: SLPs could support identification and conveying needs through posting recommendations in accessible places (e.g., in the FYI tab of the electronic health record). SLPs could train providers on communication strategies and adapt written health materials such as after visit summaries, for their patients. SLP skills are appropriate for tailoring AAC aids to each patient and to detail these in customized plans. SLPs can also support patients and their care partners in establishing communication roles in the health care encounter using a tool like the Patient–Family Agenda Tool. However, there are feasibility considerations which may be limiting wide-scale adoption of this approach. For example, accommodation activities directed at changing provider and health care organizational practices may not be reimbursed and may even detract from productivity requirements (J. Brown, 2017; Cutter & Polovoy, 2014). Additionally, even at the patient-level reimbursement is typically limited to patients with new-onset medical conditions (American Speech-Language-Hearing Association, n.d.), despite accommodations being potentially beneficial regardless of level of acuity. Future implementation research addressing barriers to SLPs adopting a communication access approach is warranted.

Limitations

There are limitations in this review. Due to the emerging nature of this area of study, no established terminology exists related to disability accommodations. As such, these terms are limited in the National Library of Medicine's standardized Medical Subject Headings. This may have resulted in missing relevant studies during our search process. We addressed this through adding citation searches and literature from our own libraries. Additionally, due to our focus on adult populations and access to health care activities in acute and outpatient settings, we did not identify potential accommodations designed for children and residential health care settings. Despite these limitations, to our knowledge, this is the first study to examine this broad body of interventions targeting equitable communication access under a policy, practice, and equity lens.

Conclusions

Communication accommodations exist in an unchartered space in health care provision. They are not direct medical treatments; however, through supporting effective communication, they have the potential to improve health care access and broader health outcomes for people with CDs. This review provided a concrete list of 10 researched accommodations targeting equitable communication access in health care. We also identified five functions of these accommodations. The 10 accommodations found and populations targeted were more wide reaching than those named in federal policy guidance, highlighting an opportunity to align policy and evidence. Study findings were typically positive, but the small sample sizes, predominantly descriptive approaches, and heterogenous outcomes suggest that efforts to synthesize the evidence would be challenging. Using our findings, we recommended strategies to advance the study of communication accommodations toward the goals of widespread adoption and effectiveness. These include using accommodation functions to address conceptual clarity and enable a basis for comparing findings, expand study populations by communication needs across health conditions, prioritize systematic identification and documentation of CD status, and reconsidering the role of SLPs.

Author Contributions

Jennifer Y. Oshita: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Visualization, Writing – original draft. Megan E. Schliep: Conceptualization, Data curation, Formal analysis, Methodology, Writing – review & editing. Natalie F. Douglas: Conceptualization, Data curation, Formal analysis, Methodology, Writing – review & editing. Liliane B. Savard: Conceptualization, Data curation, Formal analysis, Methodology, Writing – review & editing. Julie L. Feuerstein: Conceptualization, Data curation, Formal analysis, Methodology, Writing – review & editing. Charles D. MacLean: Conceptualization, Investigation, Methodology, Supervision, Writing – review & editing. Megan A. Morris: Conceptualization, Investigation, Methodology, Supervision, Writing – review & editing.

Data Availability Statement

All data generated or analyzed during this study are included in this published article.

Appendix A

MEDLINE Search Strategy

S1

exp Inpatients/or exp Outpatients/ or exp Physicians' Offices/ exp Health Services for Persons with Disabilities/ “Primary care”.ti,ab,kf. or “Acute Rehabilitation Facility”.ti,ab,kf. or “Emergency department”.ti,ab,kf. or “Emergency room”.ti,ab,kf. or critical care/ or hospitalization/ or long-term care/ exp Patient-Centered Care/ exp Nursing Homes/ health services accessibility/ academic medical centers/ or ambulatory care facilities/ or hospital units/ or hospitals/ emergency service, hospital/ patient care/ or ambulatory care/ or “continuity of patient care”/ or critical care/ or long-term care/ or nursing care/ or perinatal care/ or prenatal care/ or subacute care/ or hospice care/

S2

(communication adj3 aid*).ti,ab,kf. or “communication board”.ti,ab,kf. or (communication adj3 support*).ti,ab,kf. (communication adj3 assistan*).ti,ab,kf. or (communication adj3 strateg*).ti,ab,kf. or (communication adj3 partner*).ti,ab,kf. or (communication adj3 accommodation*).ti,ab,kf. or (speech adj3 aid*).ti,ab,kf. or (speech adj3 device*).ti,ab,kf. or (speech adj3 assistance).ti,ab,kf. or (speech adj3 tool*).ti,ab,kf. or (communication adj3 tool*).ti,ab,kf. or (voice adj3 tool*).ti,ab,kf. or (augmentative adj3 communication).ti,ab,kf. or (alternative adj3 communication).ti,ab,kf. or (supported adj3 communication).ti,ab,kf. or (hearing adj3 assistance).ti,ab,kf. or “Sign language interpreter”.ti,ab,kf. or “Computer assisted real time transcription”.ti,ab,kf. or “Adapted call light*”.ti,ab,kf. or “simplified call light*”.ti,ab,kf. or “Whiteboard”.ti,ab,kf. or “Hearing Amplifier”.ti,ab,kf. or “Voice amplifier”.ti,ab,kf. or “Clear mask*”.ti,ab,kf. or “Hospital passport*”.ti,ab,kf. or “Pocket talker”.ti,ab,kf. or “electrolarynx”.ti,ab,kf. or “visual symbol*”.ti,ab,kf. or “visual aid*”.ti,ab,kf. or “visual stor*”.ti,ab,kf. or exp amplifier/ exp alaryngeal speech/ exp larynx prosthesis/ Pictorial aid*”.ti,ab,kf. or “Pictogram*”.ti,ab,kf. or “care plan“.ti,ab,kf. or (disability adj3 nurse).ti,ab,kf. or care coordinat*.ti,ab,kf. or “environment* adaptation*”.ti,ab,kf. or “environment* modification*“.ti,ab,kf. or exp communication aid/ (healthcare adj3 accommodat*).ti,ab,kf. (health care adj3 accommodat*).ti,ab,kf. (healthcare adj3 adapt*).ti,ab,kf. or (accommodate* adj3 care).ti,ab,kf. or (disability adj3 coordinator).ti,ab,kf. or (disability adj3 worker).ti,ab,kf. or patient care planning/ “supported conversation“.ti,ab,kf. or exp mentoring/ social stor*.ti,ab,kf. or case management/ (communication adj3 device*).ti,ab,kf. or “UbiDuo”.ti,ab,kf.

S3

“Motor neuron*disease”.ti,ab,kf. or “Speech disorder*”.ti,ab,kf. or “Acquired communication disorder*”.ti,ab,kf. or “Communication Disability”.ti,ab,kf. or “Communication Disorder*”.ti,ab,kf. or “Hearing loss”.ti,ab,kf. or “Hearing disabilit*”.ti,ab,kf. or “Hearing difficult*”.ti,ab,kf. or “Deaf”.ti,ab,kf. or “Aphasia”.ti,ab,kf. or “Apraxia”.ti,ab,kf. or “Dementia”.ti,ab,kf. or “Traumatic Brain Injury”.ti,ab,kf. or “Dysarthria”.ti,ab,kf. or “Neurogenic Speech “.ti,ab,kf. or “Neurogenic Language “.ti,ab,kf. or “Learning Disabilit*”.ti,ab,kf. or “Intellectual disabilit*”.ti,ab,kf. or “Autism”.ti,ab,kf. or “Autistic adults”.ti,ab,kf. or “Developmental Disabilit*”.ti,ab,kf. or “Down* syndrome”.ti,ab,kf. or “Language disorder*”.ti,ab,kf. or “speech disabilit*”.ti,ab,kf. or “speech difficult*”.ti,ab,kf. or “Voice disorder*”.ti,ab,kf. or “Dysphonia”.ti,ab,kf. or “Aphonia”.ti,ab,kf. or “cognitive disabilit*”.ti,ab,kf. or “cognitive difficult*”.ti,ab,kf. or exp Communication Disorders/ or exp Hearing Loss/ or exp Hearing Disorders/ or exp Deafness/ or exp Aphasia/ or exp Aphasia, Wernicke/ or exp Aphasia, Broca/ or exp Dementia/ or exp Dysarthria/ or exp Memory Disorders/ or exp Developmental Disabilities/ or exp Intellectual Disability/ or exp Autism Spectrum Disorder/ or exp Autistic Disorder/ or exp Voice Disorders/ or exp Dysphonia/ or exp Aphonia/ or exp Persons With Hearing Impairments/ or exp Language Disorders/ or exp Speech Disorders/ or exp Social Communication Disorder/ or exp Brain Injuries/

S4

exp Communication Disorders/ or exp Communication/ or exp Communication Barriers/ or exp Communication Aids for Disabled/ or exp Health Communication/ or “americans with disabilities”.ti,ab,kf. or exp Health Services Accessibility/

S1 and S2 and S3 and S4

Limit to (English language and humans and yr = “2003 -Current”)

Appendix B

Scoping Review Data Extraction Fields and Response Categories

• Year of publication

• Country in which the study was conducted

  • Australia

  • Canada

  • United Kingdom and Europe

  • United States

  • Other

• Number of participants

  • Case report

  • 2–50

  • 51–100

  • > 100

• Type of CD accommodation

  • Adapted provider communication

  • Augmentative and alternative communication

  • Customized plans

  • Dedicated practitioner

  • Easy read health materials

  • Handheld communication health records

  • Hearing amplifier

  • Integrating care partner

  • Systematic identification of needs

  • Virtual visits

  • Voice amplifier

  • Free text describing the accommodation

• CD population

  • Aphasia

  • Any communication disabilities

  • Dementia or cognitive impairment

  • Hearing

  • Critical care–related aphonia/dysphonia

  • Intellectual and developmental disabilities and autism

  • Traumatic brain injury

• Health care setting

  • Inpatient acute (noncritical) care

  • Outpatient primary care

  • Intensive care unit

  • None

  • Acute rehabilitation

  • Multiple settings

  • Emergency department

  • Outpatient specialty care

• Health care workers involved in implementing the accommodation

  • Allied health assistants

  • Audiologists

  • Case managers/social workers

  • Chaplains

  • Dieticians

  • Medical office staff

  • Nurses and nursing assistants

  • Medical assistants

  • Physicians and advanced practice providers

  • Speech-language pathologists and speech-language pathology aids

  • Occupational therapists and occupational therapy aids

  • Pharmacists

  • Physical therapists and physical therapy aides

  • None

  • Other

• Type of evidence

  • Efficacy: Evaluation of the accommodation in controlled conditions. For example, researchers training providers on adapted provider communication and evaluating their confidence following the training.

  • Effectiveness: Evaluation of the effectiveness of an accommodation used in the context of real-world health care. For example, patients using pocket talkers during their emergency room visit.

  • Implementation or hybrid implementation: Research team–designed implementation of the accommodation in the context of real-world health care. These studies measure an implementation component. Hybrid implementation studies include both an effectiveness and an implementation outcome. The effectiveness outcome is the accommodation's effect on communication or health. Implementation outcomes assess the context of implementation or uptake of the intervention through its acceptability, adoption, appropriateness, feasibility, fidelity, cost, penetration, and sustainability (Proctor et al., 2011).

  • Service evaluation or quality improvement: An observational study documenting outcomes of an accommodation initiative primarily motivated by operational interests of a health organization or institution, with the intent to improve local or institutional practices.

  • Case report: An observational documentation of a single participant's experience receiving an accommodation.

• Study design

  • Randomized controlled trial: Prospective, random assignment of participants to either an experimental group receiving the intervention or a control group.

  • Nonrandomized quasi-experimental: Prospective studies testing a hypothesis comparing groups (e.g., use of a pre–post design or a control group) not using a randomized control design.

  • Descriptive/observational: Studies describing an intervention (either quantitative or qualitatively) without a hypothesis tested.

• Outcome

  • Free text

Funding Statement

The primary author was supported by a training grant provided by National Institute of Deafness and Communication Disorders 1F31DC020118-01. However, this organization was not involved in the development of the research question, study design, data collection, or analysis. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.