+--------------------------------+-------------------------------------+
| ###                            | ### VHA HANDBOOK 1174.01            |
| Department of Veterans Affairs |                                     |
+--------------------------------+-------------------------------------+
| > **Veterans Health            |                                     |
| > Administration**             |                                     |
+--------------------------------+-------------------------------------+
| > **Washington, DC 20420**     | **September 12, 2008**              |
+--------------------------------+-------------------------------------+

**BLIND REHABILITATION OUTPATIENT SPECIALIST PROGRAM PROCEDURES**

**1. REASON FOR ISSUE.** This Veterans Health Administration (VHA)
Handbook provides procedures for all matters regarding the Blind
Rehabilitation Outpatient Specialist (BROS) Program.

**2. SUMMARY OF CONTENTS.** This Handbook describes the scope of the
BROS Program and procedural guidelines for providing outpatient blind
rehabilitation services in Department of Veterans Affairs (VA) medical
facilities.

**3. RELATED ISSUES.** VHA Directive 1174 (to be published).

**4. RESPONSIBLE OFFICE.** The Office of Patient Care Services, the
Chief Consultant, Rehabilitation Services (117) is responsible for the
contents of this VHA Handbook. Questions may be referred to the
Director, Blind Rehabilitation Service at 202-461-7355.

**5. RESCISSIONS.** VHA Handbook 1174.1, dated February 16, 2000 is
rescinded.

**6. RECERTIFICATION.** This VHA Handbook is scheduled for
re-certification on or before the last working day of September 2013.

 

  ------------------------------- ---------------------------------------
                                  

                                  Michael J. Kussman, MD, MS, MACP

                                  Under Secretary for Health
  ------------------------------- ---------------------------------------

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  DISTRIBUTION:   CO:     E-mailed 9/16/08

                  FLD:    VISN, MA, DO, OC, OCRO, and 200 -- E-mailed
                          9/16/08

                          
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**CONTENTS**

**BLIND REHABILITATION OUTPATIENT SPECIALIST PROGRAM PROCEDURES**

**PARAGRAPH PAGE**

1\. Purpose 1

2\. Background 1

3\. Definitions 1

4\. Scope 6

5\. Eligibility for BROS Services 8

6\. Priority of Care 8

7\. BROS Authorized Services 9

8\. Supportive Services 10

9\. Prosthetic Equipment and Sensory Aids 12

10\. Referral Procedures 13

11\. Work Environment, Equipment, and Supplies 16

12\. Documentation and Workload Reporting 16

13\. Professional Training 17

14\. BROS Professional Competencies 17

15\. Program Oversight 18

16\. Recruitment and Promotion 18

17\. References 19

**APPENDIX**

A Algorithm for Visually Impaired Veterans A-1

**BLIND REHABILITATION OUTPATIENT SPECIALIST PROGRAM PROCEDURES**

**1. PURPOSE**

This Veterans Health Administration (VHA) Handbook describes the
procedures for the provision of services by Blind Rehabilitation
Outpatient Specialists.

**2. BACKGROUND**

a\. In 1995, VHA established the first Blind Rehabilitation Outpatient
Specialist (BROS) positions. BROS services were established to
complement the blind rehabilitation training provided at the VHA Blind
Rehabilitation Centers (BRC), and to provide blind rehabilitation
outpatient services to veterans whose rehabilitation needs are best met
in their local areas. In this role, the BROS independently conducts
assessments and training at the veteran's local Department of Veterans
Affairs (VA) facility or in the veteran's environment of choice.

b\. Combat in Operation Enduring Freedom (OEF) and Operation Iraqi
Freedom (OIF) has resulted in new patterns of polytraumatic injuries and
disability. Recognizing the specialized clinical care needs of these
individuals, VA has established a Polytrauma System of Care composed of
Polytrauma Rehabilitation Centers (PRC), Polytrauma Rehabilitation
Network Sites (PNS), and Polytrauma Support Clinic Teams and Polytrauma
Points of Contact at selected VA facilities. The BROS serves as a member
of the interdisciplinary teams (IDT) at the PRCs and PNSs, contributing
their blind rehabilitation expertise to the provision of comprehensive
rehabilitation.

**3. DEFINITIONS**

a\. **[Blind Rehabilitation Center (BRC).]{.underline}** A BRC is a
special inpatient organizational unit in a VA medical center which
provides comprehensive and individualized rehabilitation programs for
blind and visually impaired veterans and active duty service members. An
IDT approach is used in a peer support environment. Team members focus
their efforts on promoting health, developing skills of independence,
and improving the blinded veteran's adjustment to sight loss with the
ultimate goal of successfully reintegrating the individual into the
family and community environment.

b\. **[Blind Rehabilitation Outpatient Specialist (BROS).]{.underline}**
A BROS is a multi-skilled, experienced, college or university trained
blind rehabilitation specialist with a Bachelor's or Master's Degree in
Blind Rehabilitation. The BROS is a specialist with advanced technical
knowledge and competencies at the journey level in at least two of the
following disciplines: orientation and mobility, living skills (vision
rehabilitation therapy, and visual skills (low-vision therapy). The BROS
has been cross-trained to acquire broad-based knowledge in each of these
disciplines, along with knowledge of manual skills and computer access
training.

c\. **[Blind Rehabilitation Instructor.]{.underline}** This position
title refers to the BRC staff that assess, plan, and instruct in one of
the BRC disciplines. It designates an instructor with a Bachelor's,
Master's or higher degree in one or more of the specialized areas of
working with persons who are visually impaired; or a professional who
possesses a Bachelor's, Master's, or higher Degree in an allied health
profession who has expertise in one or more of the specialized areas of
working with persons who are visually impaired.

d\. **[Blind Rehabilitation Specialist.]{.underline}** This VA position
title designates a Visual Impairment Services Team (VIST) Coordinator.

e\. **[Computer Access Training.]{.underline}** This instructional area
teaches the use of specialized access equipment necessary for a visually
impaired person to independently operate computers. This includes
evaluating and training the student to use large print, synthetic
speech, or Braille access devices in order to perform basic computer
operations and maintenance.

f\. **[Continuum of Care.]{.underline}** Vision rehabilitation services
range from basic outpatient low-vision care provided by licensed eye
care practitioners or providers, to intermediate and advanced outpatient
low-vision care involving a team of eye care specialists and
rehabilitation professionals, to outpatient blind rehabilitation
services, and to inpatient blind rehabilitation services. Patients are
referred to the type program that best matches their functional needs.

g\. **[Cross-Training.]{.underline}** Cross training refers to
professional training that extends beyond an instructor's formal
training, and is intended to maximize the instructor's area of expertise
by combining specific instruction from other closely-related
disciplines. Cross-training is provided by instructors with verifiable
competencies in the BRC Program disciplines of living skills,
orientation and mobility, manual skills, visual skills, and computer
access.

h\. **[Excess Disability.]{.underline}** Excess disability is
characterized by problems and task performance difficulties related to
vision loss that have a substantial impact on the person\'s functional
independence or personal safety, and that are out of proportion to the
degree of visual impairment as measured by visual acuities or visual
fields.  Veterans whose vision is better than legal blindness may have
excess disability due to:

\(1\) Sudden or traumatic visual disorder (especially related to
military service);

\(2\) Disabling co-morbidities (e.g., hearing impairment, mobility
impairment, etc.);

\(3\) Systemic diseases that cause fluctuating visual impairment;

\(4\) Combined losses of other vision functions (e.g., contrast
sensitivity, stereopsis, etc.);

\(5\) Sudden changes in caregiver status; or

\(6\) Other reasons.

i\. **[Instruction (Basic).]{.underline}** Introductory training
addresses the skills used by visually-impaired individuals for the
management of everyday life tasks. These may include, but are not
limited to: pre-cane skills such as use of a human guide and independent
protective techniques; self-care techniques such as eating skills and
personal grooming; health management such as labeling medicines;
activities of daily living (ADLs) such as telling time, dialing a
telephone and identifying money; using talking books; and simple
adaptive kitchen skills.

j\. **[Instruction (Advanced).]{.underline}** Advanced instruction
involves the sequencing of lessons that are designed to integrate and
expand techniques taught during basic skill instruction in order to
perform more complex tasks. Examples include, but are not limited to:
business area travel such as crossing streets with traffic lights and
using public transportation, and adaptive kitchen skills such as hot
meal preparation.

k\. **[Legal Blindness (Statutory Blindness).]{.underline}** Legal
blindness exists when best corrected central visual acuity in the
better-seeing eye is less than or equal to 20/200, or visual field
dimension in the better-seeing eye is less than or equal to 20 degrees
at the widest diameter, even if central visual acuity is better than
20/200.

l\. **[Licensed Eye Care Practitioner or Provider.]{.underline}** An
optometrist or ophthalmologist is a licensed independent practitioner or
provider who examines; diagnoses; treats; prescribes medications, as
well as optical and non-optical low-vision devices, and manages eye
diseases and vision conditions within his or her clinical privileges.

m\. **[Living Skills.]{.underline}** Living skills is the instructional
area that focuses on communication skills and activities of daily
living. These skills encompass a broad range of activities including:

\(1\) Personal grooming;

\(2\) Eating skills, food preparation, household management; and

\(3\) Communication skills such as Braille, keyboarding, handwriting,
and reading with the use of electronic scanners.

n\. **[Low-Vision Clinical Examination.]{.underline}** A low-vision
clinical examination is performed by a licensed eye care practitioner or
provider that determines the veteran's level of visual impairment and
current visual functioning. It provides the best possible optical
refractive correction, and determines the patient's ability to benefit
from adaptive vision training and prescription of optical low-vision
devices, as well as non-optical or electronic devices. The low-vision
clinical examination must be performed in accordance with
nationally-published optometric or ophthalmologic clinical practice
guidelines.

o\. **[Manual Skills.]{.underline}** Manual skills are the instructional
area designed to enhance skills in sensory awareness with an emphasis on
adaptive and safety techniques. Skill training focuses on organization,
tactual awareness, spatial awareness, visual skills, memory sequencing,
problem solving, and enhances confidence. Activities range from basic
tasks using hand tools to advanced tasks using power tools and
woodworking machinery.

p\. **[National Program Consultant.]{.underline}** National Program
Consultants are professional field representatives of the Director of
Blind Rehabilitation Service. The Consultant provides ongoing support
and consultative services to the VA BRCs and Clinics, BROS and VISTs.

q\. **[Ocular Health Examination]{.underline}**

\(1\) This examination, conducted by a licensed eye care practitioner or
provider, identifies the level of, and reasons for, a person's visual
impairment. The examination includes:

\(a\) A refraction to establish best-corrected central visual acuities
(not using a preferred retinal locus),

\(b\) A thorough assessment of the visual system and ocular health to
establish the diagnosis primarily responsible for the impairment, and

\(c\) Assurance that all ocular and visual disorders are being
appropriately managed.

\(2\) If there is a significant visual field loss, a Goldmann Perimeter,
Humphry Field Analyzer, or equivalent device, is used to determine the
extent of the field loss according to the Veterans Benefits
Administration (VBA) Fast Letter 06-21 on Measurement of Visual Fields.

\(3\) The examination provides the licensed eye care
practitioner/provider with information essential to conducting or
directing additional assessments and management strategies in order to
deliver optimal visual impairment rehabilitative services.

r\. **[Optical Low-Vision Devices.]{.underline}** Optical low-vision
devices alter the image focus, size (magnification or minification),
contrast, brightness, color, or directionality of an object through the
use of lenses or other technology.

\(1\) Such devices include, but are not limited to: habitual
prescriptive spectacles (with or without tint), specialty contact
lenses, microscopic spectacles, hand-held magnifiers, stand magnifiers,
telescopes (monocular or binocular), head borne lenses, minifiers,
prisms, closed circuit televisions (CCTV), and electronic optical
enhancement devices (EOEDs).

\(2\) These optical low-vision devices must be prescribed by an
appropriately credentialed and privileged optometrist or
ophthalmologist.

s\. **[Orientation and Mobility (O&M).]{.underline}** O&M is the
instructional area that addresses the establishment and maintenance of
orientation to the environment and safe, efficient, and confident
movement in the environment. In O&M, veterans use all senses, available
environmental information, and the use of protective techniques and
devices.

t\. **[Preferred Practice Patterns]{.underline}.** Preferred guidelines
for VIST coordinators and Blind Rehabilitation Specialists (including
BROS) that specify procedures, clinical indications for performing the
procedure, clinical processes, setting, equipment specifications,
documentation aspects, and expected outcomes (see Blind Rehabilitation
Service website: <http://vaww1.va.gov/blindrehab>).

u\. **[Visual Impairment Centers To Optimize Remaining Sight
(VICTORS).]{.underline}** VICTORS are examples of outpatient low-vision
clinical programs, which provide short-term low-vision rehabilitation
for visually-impaired veterans. There are currently four VICTORS
programs located in Lake City; FL; Chicago, IL; Westport, NY; and Kansas
City, MO.

v\. **[Visual Impairment Services Outpatient Rehabilitation
(VISOR).]{.underline}** VISOR is an example of an outpatient hoptel
blind rehabilitation clinic providing an abbreviated rehabilitation
program. There are currently two VISOR programs which are located in
Lebanon, PA, and West Haven, CT.

w\. **[Visual Impairment Services Team (VIST).]{.underline}** VIST is
comprised of health care and allied health care professionals charged
with the responsibility of ensuring that blind veterans are identified,
evaluated, and provided health and rehabilitation services to maximize
adjustment to sight loss. Representatives may include, but are not
limited to: social work, ophthalmology, optometry, prosthetics, primary
care, vocational rehabilitation, library service, nursing, audiology,
podiatry, nutrition, psychology, VBA, blind veterans' consumer
organizations, blind consumers, and state or community agencies for
persons who are blind.

x\. **[VIST Coordinator.]{.underline}** The VIST Coordinator serves as
the case manager who has major responsibility for the coordination of
services for visually-impaired veterans and their families, and is often
the entry point into the continuum of care for visually-impaired
veterans. Duties include arrangement of appropriate rehabilitation
services and devices in order to enhance a visually impaired veteran's
functioning level (e.g., referrals to the VA's Continuum of Care, as
well as outsourced services in order to enhance the veteran's
functioning level). Other duties include identifying new cases of
blindness, providing professional counseling, meeting specific
objectives established by the VIST, arranging VIST Reviews, and
conducting educational programs relating to VIST and blindness.

y\. **[VIST Annual Report.]{.underline}** An annual narrative is
completed by all VIST Coordinators and submitted to Blind Rehabilitation
Service, VA Central Office, through local administrative channels. The
report details program developments, program highlights, and program
goals. A copy of the report is sent to the National Program Consultant
responsible for the VIST designated area, and is due no later than
October 31st of each year.

z\. **[VIST Review]{.underline}**

\(1\) In this review, the VIST Coordinator conducts an assessment of the
veteran's history, current skills level, adjustment to blindness, and
needs.

\(2\) The VIST review includes: a comprehensive physical examination and
ocular health examination, an audiological or low-vision clinical
examination, and a VIST assessment of patient history, current skill
levels, adjustment to visual impairment, and needs.

\(3\) This review establishes a description of the veteran\'s functional
capabilities and limitations. The VIST Coordinator develops a treatment
plan, which includes recommendations for other needed exams, services,
and follow-up. When the VIST Coordinator utilizes reports from
evaluations accomplished during the preceding year, this is called a
"Component Annual Review."

aa. **[Visual Skills.]{.underline}** Visual skills training enables
veterans to gain a better understanding of their eye problems, and
teaches them how to effectively utilize their remaining vision through
techniques that improve visual perceptual and visual motor function.
Visual skills training includes assessment and intervention with special
low-vision devices designed to meet the various needs of the person
served. These needs may include, but are not limited to, reading,
activities of daily living, orientation and mobility, and home repairs.

**4. SCOPE**

a\. **[Mission]{.underline}**

\(1\) BROS outpatient services are designed to complement the inpatient
blind rehabilitation services provided at the VHA BRCs and Clinics, and
to provide blind rehabilitation care to veterans whose rehabilitation
needs are best met in their local areas. The BROS conducts assessments
and training at the veteran's local VA facility or in the veteran's
environment of need. This program design supports an effective continuum
of care by providing immediate and individualized rehabilitation in
locations that are accessible, and in settings that are the most
appropriate for the veteran.

\(2\) The BROS also serves as a member of IDT at PRCs and PNSs;
contribute their blind rehabilitation expertise to the provision of
comprehensive rehabilitation services for individuals with complex
physical, cognitive, and mental health sequelae of severe and disabling
trauma.

b\. **[Services.]{.underline}** Services for all BROS include:

\(1\) **Assessments.** The BROS conducts assessments of patients in one
or more of the key skill areas of blind rehabilitation. The basis of all
intervention is to enhance function and help to develop compensatory
strategies to deal with sight loss.

\(2\) **Interdisciplinary Treatment Planning.** Patients' individualized
treatment plans are developed based on the identified needs and stated
goals of the veterans.

\(3\) **Training.** The specific training provided to individual
patients varies, depending on the veteran's needs and abilities. Such
training may be provided at local medical centers, in client's homes or
local communities, and in other environments where the veteran is likely
to travel or perform ADLS. Instruction may be short or moderately
long-term, although those individuals with extensive needs are
encouraged to utilize the comprehensive rehabilitation services
available at a VHA Blind Rehabilitation Center or other appropriate
outpatient program within the Continuum of Care.

\(4\) **Prosthetic Recommendation.** Based on assessment of veteran
needs, BROS recommends issuance of prosthetic aids and appliances
related to vision loss within their scope of practice in accordance with
VHA policy.

\(5\) **Consultative Services.** The BROS provides consultative services
in response to requests for information on vision loss and blindness.

\(6\) **Veteran and Family Counseling and Education.** The BROS provides
veterans and their families with education and assistance in
understanding and adjusting to the effects of vision loss.

\(7\) **Staff Education and Community Outreach.** As a subject matter
expert in the field of blindness, the BROS provides education and
training in the dynamics of blindness, low-vision and VA blind
rehabilitation services.

c\. **[Outpatient Model of Care]{.underline}**

\(1\) In the BROS model, blind and visually impaired veterans receive
blind rehabilitation services through local assessment and training to:

\(a\) Meet the immediate needs of veterans that impact safety,

\(b\) Prepare for or complete an inpatient Blind Rehabilitation Center
or Clinic program, or

\(c\) Provide blind rehabilitation to veterans whose training needs are
best met in their local areas.

[]{.mark}

\(2\) Each BROS has a defined geographic service area. In most cases,
the primary service area corresponds to the service area for the VA
facility where the BROS is located. However, BROS programs may serve one
or more VA facilities, as resources and needs indicate.

***NOTE:** BROS serving at the Network Polytrauma Sites may have
additional duties related to Polytrauma that include areas larger than
their normal geographic boundaries.*

\(3\) Coordination of care. Facilities shall coordinate the provision of
blind rehabilitation services for veterans with services for the care of
the visually impaired offered by State and local agencies, especially to
the extent to which such State and local agencies can provide necessary
services to blind veterans in settings located closer to the residences
of such veterans at similar quality and cost to the veteran (from Public
Law 109-461).

d\. **[Polytrauma Rehabilitation Model Of Care]{.underline}**

\(1\) BROS are involved in the provision of services at all points
within the Polytrauma System of Care. This includes Military Treatment
Facilities, PRCs, PNSs, and in the individual's home area.

\(2\) Interdisciplinary patient care. The BROS is a member of the
interdisciplinary treatment team. This team, characterized by a variety
of disciplines working together, conducts assessment, planning, and
implementation of the patient's care plan. Continuous communication,
collaboration, and coordination are critical to avoid fragmented care.
The team functions as a unit, cooperating among disciplines to achieve
maximum patient and family outcomes.

\(3\) Interdisciplinary Assessments. Each patient receives a full
interdisciplinary assessment which is used to prepare individualized
care plans for the patients. BROS assessments will relate to their areas
of expertise.

\(4\) Interdisciplinary Treatment Plans. Each patient must have a
coordinated and integrated interdisciplinary plan of care that includes
all required disciplines and reflects the goals of the patient and
family. The treatment plan addresses the veteran's goals and is
individualized to meet the veteran's needs relevant to lifestyle, age,
level of capability, and future plans.

\(5\) Interdisciplinary Care Delivery. Treatment team members
continually evaluate performance results during the veteran's
rehabilitation program, as they relate to expected outcomes, in order to
determine the appropriateness of the treatment being provided. Any
revisions to the treatment plan are made with the veteran's involvement.
Revisions are based on demonstrated strengths, changing needs, and
expected outcomes in order to ensure that goals are achievable and
meaningful to the person receiving services. Team meetings are held when
needed to monitor progress and update the care plan to reflect progress
and new patient goals.

**5. ELIGIBILITY FOR BROS SERVICES**

a\. Blind Rehabilitation Service is committed to serving all eligible
veterans and active duty personnel who need and can benefit from its
unique services. Legal blindness based on measurement of visual acuity
and visual fields have long been recognized as indicators of disability,
and continue to be a primary test of eligibility for VHA blind
rehabilitation services. Eligibility criteria for blind rehabilitation
services must also address functional deficits and the rehabilitation
needs of the person because of the complex relationship between visual
function and the overall functional capacity of the individual.

b\. In order for a person to be eligible for BROS services, the person
must be enrolled in VA health care and meet one of the following
criteria:

\(1\) Best corrected central visual acuity in the better-seeing eye less
than or equal to 20/200, or visual field dimension in the better-seeing
eye less than or equal to 20 degrees at the widest diameter, even if
central visual acuity is better than 20/200.

\(2\) Blind rehabilitation services are needed for appropriate
restoration of the individual\'s safety, functional independence, or for
facilitating their personal or social adjustment to vision loss. This
need may be based on the visual impairment alone or in combination with
excess disability factors

**6. PRIORITY OF CARE**

a\. Priority of care will be provided to active duty military personnel,
service-connected veterans rated 50 percent or greater for any
combination of disabilities, and veterans who are service-connected for
their visual impairment.

b\. The priority for care also considers urgent need factors, such as:

\(1\) Safety issues,

\(2\) Medical issues,

\(3\) Lack of a caregiver,

\(4\) Vocational needs (e.g., attending school, employed),

\(5\) No previous history of blind/vision rehabilitation services**.**

**7. BROS AUTHORIZED SERVICES**

a\. **[Assessments]{.underline}**

\(1\) A BROS must conduct assessments of all clients. Assessments serve
as the basis for all interventions designed to enhance function and
develop compensatory strategies to deal with sight loss. These
assessments address vision loss and safety needs that require immediate
intervention.

\(2\) A BROS must conduct blind or vision rehabilitation assessments
with veterans identified by VIST as needing a BROS program prior to
being admitted to a BRC. The assessments includes evaluations in
orientation and mobility, living skills, manual skills, visual skills,
and (when indicated) computer access. The assessment format is mutually
developed by the BROS and the BRC of jurisdiction, based on nationally
designed blind rehabilitation standards. During the evaluation, the BROS
assesses each veteran's abilities and needs for blind rehabilitation
training, and addresses the veterans goals and readiness for any
recommended training.

\(3\) A BROS must ensure that veterans with visual impairment who have
vision receive a low-vision clinical examination by a licensed and
priviledged eye care practitioner or provider. The BROS will work with
the optometrist or ophthalmologist to develop a visual rehabilitation
treatment plan utilizing optical low-vision devices that were prescribed
by an appropriately credentialed and privileged licensed eye care
practitioner or provider and well as useful non-optical devices that
enhance the use of vision.

b\. **[Treatment Planning.]{.underline}** Based on assessment results
and in collaboration with the patient, BROS are required to develop a
treatment plan addressing the veteran's specific needs and goals related
to blindness and visual impairment. The treatment plan considers all
available options for evaluation, training (VA and non-VA), issuance of
prosthetics in accordance with VHA policies, and the setting which best
meets the veteran's needs. The treatment plan is documented in the
medical record, and is communicated to the VIST Coordinators and other
services, as appropriate.

c\. **[Instruction and Training.]{.underline}** The BROS is authorized
to provide blind rehabilitation training in the following blind
rehabilitation skill areas: living skills, manual skills, orientation
and mobility, visual skills, and computer access. The training program
includes instruction in the use of assistive devices and equipment.

d\. **[Veteran and Family Education and Counseling.]{.underline}** The
BROS provides education and counseling to veterans and their family
members in order to facilitate maximum adjustment to vision loss.

e\. **[Use of VA and Non VA Services.]{.underline}** The BROS
collaborates with the local VIST Coordinator to ensure that eligible
blinded veterans are aware of services and benefits available to them
through and outside VA. Where appropriate, a BROS will assist in the
veteran's application for such services.

f\. **[Referral to Appropriate VA Healthcare Services.]{.underline}**
The BROS works with veterans' health care providers to support the
health care needs of veterans served by the BROS program. Referrals of a
routine nature may be made through the VIST Coordinator as Case Manager.

g\. **[Prosthetic Recommendation.]{.underline}** The BROS is authorized
to determine veterans' needs for prosthetic equipment related to vision
loss. The BROS recommends issuance of prosthetics in accordance with
relevant VHA Directives, VHA Handbooks, VHA Prosthetic Clinical
Management Program (PCMP) Clinical Practice Recommendations policies,
and existing national contract prosthetic guidelines on Aids for the
Blind.

h\. **[Project Participation.]{.underline}** The BROS will participate
in projects in support of the VHA Blind Rehabilitation Service program
office.

**8. SUPPORTIVE SERVICES**

a\. **[VA Medical Centers.]{.underline}** The BROS and VIST Coordinators
are key links between the VA facility, visually impaired veterans and
their families, and the community. These links may serve as a powerful
connection for visually impaired veterans in accessing the benefits and
services provided by state and community blindness agencies, consumer
groups, and veterans' service organizations. BROS should be involved in
the review and updating of facilities Guide Dog policies and provisions.

b\. **[Ophthalmology or Optometry Service.]{.underline}** Ophthalmology
Service or Optometry Service provide ocular health examinations,
low-vision clinical examinations, treatment and management of ocular
diseases and vision disorders as appropriate, and determination of
visual function. Ophthalmologists and Optometrists must prescribe all
optical low-vision devices and may provide basic instruction in their
use. The BROS and eye care staff work cooperatively to ensure that
veterans receive appropriate vision rehabilitation services.

c\. **[Prosthetic and Sensory Aid Service (PSAS).]{.underline}** PSAS
provides prosthetic equipment and services appropriate to the needs of
visually impaired clients, and maintains sufficient stock to ensure
prompt availability.

d\. **[VIST Coordinator.]{.underline}** The VIST Coordinator is
responsible for:

\(1\) Identification and screening of blinded veterans, and assisting as
necessary with enrollment in VA healthcare.

\(2\) Making the eligible veterans aware of services and benefits
available to them through VA and Non-VA sources, and where appropriate,
assisting veterans to apply for such services.

\(3\) Assisting eligible veterans to apply for blind and low-vision
rehabilitation training programs.

\(4\) Recommending prosthetic equipment for blinded veterans who may or
may not be participating in the BROS or BRC Programs in accordance with
VHA Handbooks, VHA Directives, and VHA PCMP Clinical Practice
Recommendations policies.

\(5\) Coordinating non-BROS program training activities of veterans
currently active in the BROS Program.

\(6\) Serving as liaison with local non-VA agencies, together with the
BROS, to assist in the identification and/or provision of services to
blinded veterans. The VIST coordinator has primary responsibility for
making referrals and monitoring the progress of services provided by
these agencies with assistance from the BROS and licensed eye care
practitioners/providers to develop and help maintain relationships with
local non-VA agencies.

\(7\) Coordinating the activities of the VIST.

e\. **[Inpatient Blind Rehabilitation Centers.]{.underline}** The
inpatient BRC is responsible for:

\(1\) Coordinating the admission date, treatment planning, and
post-discharge care with the BROS in a timely manner for veterans
according to VHA policy.

\(2\) Providing interdisciplinary assessment and evaluation, planning,
and intensive blind rehabilitation for veterans and active duty
personnel.

\(3\) Providing training for the BROS.

f\. **[Outpatient Blind Rehabilitation Clinics.]{.underline}** An
intermediate low-vision clinic, advanced low-vision clinic or outpatient
blind rehabilitation clinic is responsible for:

\(1\) Providing low-vision clinical examinations by an appropriately
credentialed and privileged optometrist or ophthalmologist in accordance
with nationally published optometric or ophthalmologic clinical practice
guidelines, performing functional assessments of daily living abilities,
vision rehabilitation planning, prescription of low-vision and other
prosthetic devices according to VHA policies, and vision and blind
rehabilitation training for veterans and active duty personnel.

\(2\) Coordinating the rehabilitation care with BROS to ensure follow-up
and outcomes assessment for veterans post-discharge.

\(3\) Providing training for BROS.

g\. **[VHA National Program Consultant.]{.underline}** The National
Program Consultant is responsible for:

\(1\) Assisting in the initial orientation and training of new BROS
through direct training and establishment of mentoring programs;

\(2\) Assisting BROS in developing personal development plans that
address personal mastery, technical skills, customer services, and other
aspects of the VA's High Performance Development Model;

\(3\) Assisting BROS in quality improvement efforts.

**9. PROSTHETIC EQUIPMENT AND SENSORY AIDS**

a\. **[Issuance.]{.underline}** Prosthetic issuance isin accordance
with:

\(1\) VHA Handbook 1173.5, Aids for the Blind.

\(2\) VHA Handbook 1173.2, Furnishing Prosthetic Appliances and
Services.

\(3\) VHA Handbook 1173.12, Prescription Optics and Low-Vision Devices.

\(4\) VHA policies on Prescribing Hearing Aids and Eyeglasses.

\(5\) VHA Prosthetics Clinical Management Program (PCMP) Clinical
Practice Recommendations policies pertaining to issuance, prescription
and provision of prosthetics.

\(a\) VHA PCMP Clinical Practice Recommendations on Prescription and
Provision of Optical Low-Vision Devices to Aid in Overcoming Visual
Impairment.

\(b\) VHA PCMP Clinical Practice Recommendations for Prescription of
Closed Circuit Televisions (CCTVs) and Other Electronic Optical
Enhancement Devices (EOED).

\(c\) VHA PCMP Clinical Practice Recommendations for Prescription and
Provision of Daily Living and Mobility Devices for Legally Blind and
Visually-Impaired Veterans.

\(d\) VHA PCMP Clinical Practice Recommendations for Audible
Prescription Reading Devices.

\(e\) Other policies listed on the Prosthetics and Clincal Logistics
Office website at:
[http://vaww.pclo.med.va.gov](http://vaww.pclo.med.va.gov/)

\(6\) Existing national contract guidelines on Aids for the Blind.

b\. **[Criteria for Issuance]{.underline}**. Candidates must demonstrate
the ability to utilize the equipment for the identified needs. Required
documentation includes identification of need, training provided, and
the capability of the veteran to utilize the equipment.

c\. **[Recommending Authority]{.underline}**

\(1\) The BROS may provide initial issuance of all non-optical and blind
aids, provided the veteran has completed the required training and
demonstrated the ability to properly use the requested equipment. The
initial issuance of optical low-vision devices by the BROS requires
prescription or concurrence from a licensed eye care
practitioner/provider.

\(2\) Requests for prosthetics by non-VA service providers as part of
community-based programs of instruction should be addressed by, or
referred to the VIST Coordinator as case manager for the veteran.

\(3\) The BROS may provide replacement equipment and equipment upgrades
for veterans who have participated, but are not currently participating,
in a VA blind rehabilitation program. Where such upgrades require
extensive re-training (e.g., new computer technology), the BROS will
inform the VIST Coordinator who will coordinate a referral to the
appropriate source, and monitor the progress of such instruction.

d\. **[Pre-BRC Issued Equipment.]{.underline}** When prosthetic
equipment is issued prior to a veteran's admission to a BRC program, the
BROS will encourage the veteran to bring the equipment to the BRC as
appropriate. This enables the veteran to continue to use the equipment
he has found useful, receive instruction or review in the use of the
device if needed, or make any necessary adaptations to the veteran's
equipment.

**10. REFERRAL PROCEDURES**

a\. **[Non BRC Referral.]{.underline}** The process for referral is as
follows:

\(1\) **Identification.** The VIST Coordinator identifies the blinded
veteran and coordinates services that include an ocular health
examination, medical evaluation, psychosocial interview and patient
education.

\(2\) **VIST** Responsibilities**.** The VIST Coordinator completes a
VIST assessment, which describes the veteran's functional capabilities
and limitations and includes a patient history, adjustment to blindness
issues, and veteran's goals.

\(3\) **BROS** Program Open Cases or Priority of Care**.** The BROS
opens a case after a referral has been received from the VIST
Coordinator. The BROS program will be provided according to the
priorities previously described in this handbook.

\(4\) **BROS** Program Assessment**.** The BROS conducts individualized
assessments that may include: visual skills, orientation and mobility,
living skills, manual skills and limited computer access training (as
necessary), and documents the veteran's capabilities and needs.

\(5\) **BROS Program Individualized Treatment Plan.** The BROS, with
input and concurrence from the veteran, develops an individualized
treatment plan. The treatment plan includes: assessment results, veteran
or family treatment program goals, objectives and recommendations for
intervention. The treatment plan is documented in the veteran's record
and the Blind Rehabilitation database. The BROS refers the patient to
the VIST Coordinator documenting the need for referral to VHA low-vision
services, local resources, including recommendations for particular
instructors if available and appropriate. The VIST Coordinator is then
responsible for making all necessary arrangements, and for monitoring
the progress of the local services provided.

\(6\) **Rehabilitation Training.** The BROS provides training in their
areas of expertise. The VIST Coordinator refers to qualified agencies as
appropriate. When referring to non-VA agencies, the VIST Coordinator
monitors the treatment process and keeps the BROS informed of any
developments including the need to participate in revisions of the
original referral objectives.

\(7\) **BROS Program Completed Services.** A veteran's case is closed
with the BROS once goals and objectives are achieved, the patient's
progress plateaus, the patient declines further service, or the patient
is unable to participate in further service. If the veteran is referred
for training in another element of the Continuum of Care or to a non-VA
agency and follow-up services by a BROS are anticipated, the case will
be closed after completion of the BROS follow-up treatment. When the
case is closed, the BROS will enter a final summary in the veteran's
medical record and inform the VIST Coordinator of the case closure. The
VIST Coordinator will monitor the veteran's progress and make a referral
to the BROS as indicated.

b\. **[BRC Referral.]{.underline}** The BRC referral process for
outpatients is as follows:

\(1\) **Identification.** The VIST Coordinator identifies the blinded
veteran and schedules a VIST Review. The VIST Review provides an
evaluation that includes an ocular health examination, medical
evaluation, hearing exam, initial benefit review, psychosocial
interview, and patient education.

\(2\) **BRC Referral Procedure.** BRC referral procedures are completed
by the VIST Coordinator. If there is an expectation of a BROS
involvement, a referral is forwarded to the BROS.

\(3\) **BRC Referral Review.** The BRC Program reviews the referral and
supporting documentation and decides within 20 working days whether to
accept or deny for admission.

\(4\) **BRC Admissions Waiting List Referrals.** Applications received
are automatically placed on the BRC Waiting List and placed in the
"pending" status until the BRC Chief, or designee, starts the review
process of the application. Referrals in the "pending", "review" and
"accept" status are on the waiting list. Referrals requiring additional
information are placed in the "in review" status while awaiting receipt
of the requested information. The VIST Coordinator responsible for
providing the additional information must respond with a plan of action
within 10 working days and ensure the requested information is received
by the BRC within 30 days, or provide justification for the delay in
providing the necessary information (note: up to 90 days is permitted
for patient issues related to Audiology). The status of any referral can
be viewed in the Blind Rehabilitation National Database.

\(5\) **BROS Opens Cases.** The BROS opens a case after a written
referral has been received from the VIST Coordinator requesting
pre-admission services.

\(6\) **BROS' Assessments.** The BROS conducts an individualized
assessment, including evaluations in Visual Skills, Orientation and
Mobility, Living Skills, Manual Skills, and (when indicated) Computer
Access in order to:

\(a\) Identify goals and determine needs,

\(b\) Evaluate the veteran's ability to learn and retain information,
and

\(c\) Determine the veteran's readiness for inpatient training.

\(7\) **BROS' Individualized Treatment Plans.** The BROS, with input and
concurrence from the veteran, develops an individualized treatment plan.
The treatment plan includes assessment results, veteran or family
training program goals, objectives and recommendations for intervention.
The treatment plan is documented in the veteran's record.

\(8\) **Pre-BRC Training.** The BROS conducts pre-BRC training to
address a veteran's urgent needs and documents services provided,
informing the BRC that such training has been initiated so that the BRC
is informed of the ongoing involvement of the BROS.

\(9\) **Admission to BRC.** In those cases where a BROS has been
providing local training, the BRC will coordinate admission with the
BROS.

\(10\) **BRC Program.** The BRC creates an individualized training
program that addresses the veteran\'s needs, making reference to the
BROS's program progress notes and recommendations and its own assessment
processes. When possible and appropriate, the BROS will participate in
veteran's staffing and discharge planning.

\(11\) **Post-BRC Training and Follow-up.** Following BRC services, and
with consideration of final summaries and recommendations of the BRC
staff, the BROS may provide additional services in the veteran's home
and local community to meet the veteran's individual rehabilitation
needs.

\(12\) **BROS' Completed Services.** A veteran's case is closed with the
BROS once the veteran's goals and objectives have been achieved, the
patient's progress plateaus, the patient declines further service, or
the patient is unable to participate in further service. A final summary
is documented in the veteran's medical records and the VIST Coordinator
is informed. The veteran will continue to be followed by the VIST.

**11. WORK ENVIRONMENT, EQUIPMENT, AND SUPPLIES**

a\. **[Work Environment, Safety, Equipment and Supplies.]{.underline}**
The work environment for a BROS encompasses a wide range of areas
including, but not limited to:

\(1\) VA facilities,

\(2\) Veteran's home and immediate neighborhood,

\(3\) Employment sites,

\(4\) School campuses,

\(5\) Residential areas,

\(6\) Rural areas, and,

\(7\) Downtown and urban areas.

b\. **[Office Space.]{.underline}** Each BROS program needs adequate
office and clinical space to conduct assessments, demonstrate adaptive
equipment (e.g., closed-circuit televisions and adapted computer
systems), and provide training in multiple skill specialty areas to
blinded veterans. The assigned space should be a minimum of 650 square
feet, located in an area that is accessible and convenient to the
blinded veterans.

c\. **[Government Vehicle.]{.underline}** BROS assessment and training
must be conducted in areas that are specific to the individual needs of
veterans. This requires frequent travel by government vehicle and public
transportation wherever that may be available to veterans, often over a
wide geographic area. Immediate access to vehicles is important to
ensure an efficient assessment process. Each BROS is assigned a
government vehicle for sole use to support efficient patient care.
Public transportation rail/bus passes may also be required.

d\. **[Budget.]{.underline}** BROS programs are provided with start-up
and ongoing operational funding to purchase training equipment, office
equipment, and supplies. During outpatient training, the BROS may
temporarily loan equipment as part of the evaluation and training
process. The BROS program is expected to have sufficient funds available
for the purchase and maintenance of a limited selection of loaner items.

**12. DOCUMENTATION AND WORKLOAD REPORTING**

a\. The documentation of patient assessments, treatment plans, and
progress notes must be consistent with VA requirements, as well as the
requirements of The Joint Commission (TJC).

b\. Workload data (i.e., encounter codes and Decision Support System
information) are entered according to local medical facility policy. The
stop code "217" is used to capture BROS program workload. Additional
activities not captured by this stop code are noted in the VIST Program
Annual Report.

c\. The BROS records clinic activity in the BRS national database and in
the electronic medical record. This includes: assessment, referrals,
training, discharge summary and other patient encounter information.

d\. The BROS will cooperate and participate in projects related to the
Blind Rehabilitation Service, as directed by VA Central Office.

**13. PROFESSIONAL TRAINING**

a\. VHA Blind Rehabilitation Service provides professional continuing
education and training programs for BROS.

b\. New BROS must participate in training to enhance their skills and
develop a cooperative working relationship with all other BRS field
elements. The cross-training curriculum must include:

\(1\) Training in policies and procedures related to BRC services
provided by the National Program Consultants, and at the regional BRC
Program that serves the VA facility where the BROS program is located.

\(2\) Instruction in assessment and patient training in blind
rehabilitation skill areas for which the BROS instructor is not already
proficient. Much of this instruction can be provided at the regional
BRC.

\(3\) Activities that encourage teamwork and facilitate communication
between the BROS and other BRS field staff.

\(4\) A mentoring program under the oversight of an established BROS and
a National Program Consultant.

\(5\) An orientation to the duties and responsibilities of the VIST
Coordinator and creation of collaborative protocols for serving the
blinded veterans in their area.

\(6\) Training on the VA organizational structure, policy and procedures
will be provided at the BROS' local facility.

**14. BROS PROFESSIONAL COMPETENCIES**

a\. BROS must have professional training and skills in two of the three
rehabilitation areas listed below. The educational requirements and
expected competencies for each of these areas are:

\(1\) **Orientation and Mobility.** Requires a BROS with a degree from
an accredited college or university and who has met the core curriculum
requirements in orientation and mobility, and has completed a supervised
orientation and mobility internship.

\(2\) **Living Skills (vision rehabilitation therapy).** Requires a BROS
with a degree from an accredited college or university and who has met
the core curriculum requirements in vision rehabilitation therapy, and
has completed a supervised vision rehabilitation therapy internship.

\(3\) **Visual Skills (low-vision therapy)**. Requires a BROS with a
degree from an accredited college or university and met the core
curriculum requirements in low-vision therapy, and has completed a
supervised low-vision therapy internship.

b\. Polytrauma BROS must meet their two journeyman areas of expertise
requirements in orientation and mobility and low-vision therapy.

c\. In addition to the two areas of advanced technical knowledge and
competence, BROS are expected to be knowledgeable of all components of a
comprehensive blind rehabilitation program (i.e., orientation and
mobility, living skills, visual skills, manual skills, and computer
access) in order to provide services in all areas of blind or low-vision
rehabilitation.

d\. BROS are expected to maintain their expertise by attending all BROS
training provided by Blind Rehabilitation Service (BRS)-VA Central
Office, as well as other training providing within and outside VHA.

**15. PROGRAM OVERSIGHT**

a\. **[VHA Blind Rehabilitation Service Oversight.]{.underline}**
National Program Consultants perform ongoing review and evaluation of
BROS programs to ensure that blind rehabilitation outpatient services
are being provided in an effective and efficient manner.

b\. **[Consumer Feedback and Input.]{.underline}** In coordination with
the local VIST Coordinator, BROS establish a mechanism to solicit blind
and visually-impaired veteran feedback and input concerning the overall
quality of care and services provided to them. This can be accomplished
by periodic surveys, consumer forums, and input from local Blinded
Veterans Association and other consumer group representatives.

**16. RECRUITMENT AND PROMOTION**

a\. I n a health care facility where a BROS position exists or is to be
established, the position should be organizationally aligned under the
Chief of Staff. The BROS positions are advertised at the medical center
in which the position resides. Positions are Hybrid Title 38 positions
and require a VA BRS Professional Standards Board (PSB) review and
recommendation.

b\. Although the full performance level position is at the GS-12,
recruitment may be at the GS-11 level. The position may be filled
non-competitively at the target grade by reassignment of eligible
candidates or qualified higher level candidates may change to the lower
grade. The position may also be filled by qualified candidates eligible
for excepted appointments under the Schedule A, and the \'30 Percent\'
Disabled Veteran Appointment Authorization.

c\. Promotion to the target grade will depend on professional
competence, performance and program development.

d\. Each health care facility having a position identified as Blind
Rehabilitation Outpatient Specialist, GS-601-11, or GS-601-12, must
ensure that the position description or functional statement reflecting
the position\'s organizational alignment under the Chief of Staff, is
current and available upon request.

e\. The facilities must notify BRS, VHA Central Office of vacancies in
BROS positions, requesting assistance in recruitment. The recruiting
facility determines the grade level at which the position will be filled
and forwards the name of the appropriate candidate to the PSB for
review.

f\. In order to promote the incumbent to the full performance level, the
facility must obtain the approval of the VA BRS PSB.

**17. REFERENCES**

a\. Optometric Clinical Practice Guidelines, American Optometric
Association at: (<http://www.aoa.org/x4813.xml>)

b\. Preferred Practice Patterns, American Academy of Ophthalmology at:
(<http://one.aao.org/CE/PracticeGuidelines/PPP.aspx>)

c\. Social Security Disabilities Programs, Medical/Professional
Relations, Disability Evaluation under Social Security, Section 2.00
Special Senses and Speech, Statutory Blindness at:
(<http://www.ssa.gov/disability/professionals/bluebook/2.00-SpecialSensesandSpeech-Adult.htm>)

d\. Veterans Benefits Administration, Fast Letter 06-21, Measurement of
Visual Fields.

e\. VHA Handbook 1173.5, Aids for the Blind.

f\. VHA Handbook 1173.2, Furnishing Prosthetic Appliances and Services.

g\. VHA Handbook 1172.1, Polytrauma Rehabilitation Procedures.

h\. VHA Handbook 1173.12, Prescription Optics and Low-Vision Devices.

i\. VHA Handbook 1121, VHA Eye Care.

j\. VHA Prosthetic Clinical Management Program (PCMP) Clinical Practice
Recommendations for Audible Prescription Reading Devices.

k\. VHA Prosthetic Clinical Management Program (PCMP) Clinical Practice
Recommendations for Prescription of Closed Circuit Televisions (CCTVs)
and Other Electronic Optical Enhancement Devices (EOED).

l\. VHA Prosthetic Clinical Management Program (PCMP) Clinical Practice
Recommendations for Prescription and Provision of Daily Living and
Mobility Devices for Legally Blind and Visually-Impaired Veterans.

m\. VHA Prosthetic Clinical Management Program (PCMP) Clinical Practice
Recommendations on Prescription and Provision of Optical Low-Vision
Devices to Aid in Overcoming Visual Impairment.

**ALGORITHM FOR VISUALLY IMPAIRED VETERANS**

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