1. BrICC Brain Injury & Concussion Clinic CLINICIAN TRAINING
Summer 2017
Communication Disorders & Sciences University of Oregon

2. Training Overview PART 1 PART 2 Welcome & Introductions
BrICC student expectations
Clinic Purpose & Populations
Rounds and Rounds Portfolio
Cognitive Domains
Supervision: group, self-reflections
Resources on infoCDS
Documentation: expectations, reflecting on changes; due dates
Principles of Assessment
Principles of Treatment
eGAS practice

3. Learning Objectives
By the end of today’s training, you should be able to….
Describe the purpose of BrICC and characteristics of client populations.
Identify special features of the BriCC clinic experience that may be different from other specialty clinics.
Describe components of an initial cognitive consultation and how to prepare.
Explain guiding principles of treatment selection and delivery in BrICC.
Locate checklists, templates, and instructions on infoCDS to assist you in preparing for rounds, consults, treatment, and completing required documentation.
Make sure that you ask about anything that is unclear, and feel comfortable contacting your supervisor (Alex or Heidi) by to clarify any further questions that come up.

4. Part 1

5. Welcome & Introductions
Two BrICC supervisors during the summer:
Alex Ledbetter, PhD, CCC-SLP – will be in touch by , will return Thursday, July 6
Heidi Iwashita, M.S., CCC-SLP
Self-introduction/Icebreaker – a) what’s the best thing that’s happened to you this week or last week? b) What is something you are excited about or wondering about regarding BrICC?

6. Before this training, have you…
Checked your schedule provided by Alex in the dated 6/27, and contacted him if you have any questions about scheduling/assignments?
Confirmed session times with clients?
Asked clients if they prefer to get reminders before each session?
Taken the pre-practicum survey? (if not, we will take a few minutes to finish it now)

7. Clinic Purpose
Complete initial consultation to assess acquired cognitive impairments and identify client desired outcomes
Identify nature of cognitive impairments and impact on activities and participation
Provide cognitive rehabilitation and/or counseling for individuals experiencing impact on function
Facilitate attainment of desired outcomes in desired contexts or settings - getting back to valued roles/activities

8. Clinic Purpose Individual sessions focus on client’s area of need
Group sessions facilitate peer support
Interdisciplinary collaboration opportunities
Holistic rehabilitation experience
Enhance case management

9. Populations seen in BrICC
Acquired brain injury (ABI) - mild, mod, severe
Acquired cognitive impairments
Traumatic brain injury (TBI)
Concussion
Persistent symptoms, multiple concussions
Neurogenic populations with cognitive impairments
e.g., Parkinson’s, Huntington’s, stroke, primary progressive aphasia

10. Population Characteristics
Cognitive symptoms
--Impaired attention, memory, executive function
Somatic symptoms
--Headache, light sensitivity, nausea, dizziness
Psychosocial changes
--Decreased social engagement, irritability, flat affect

11. Cognitive domains addressed in BrICC
Attention
Memory
Executive Function
Social communication (e.g. pragmatics, theory of mind, social problem solving)

12. Understanding cognitive domains
Clinical decisions should be based on an understanding of WHAT underlying cognitive domain you are treating, as well as WHY and HOW you are treating it
Confusing domains can impact clinical decision making and client progress
When explaining assessment and treatment options to clients, use simple language to talk about “attention,” “executive functions,” and different types of memory – examples help
With a clear understanding of cognitive domains, you will write clearer goals, ITPs, and assessment reports with fewer supervisor edits

13. Attention Focused Attention – put your attention on something
Sustained Attention – keep your attention on something
Working Memory – hold info in mind to use it in some way
Suppression – ignore, suppress, inhibit what you don’t need to attend to
Alternating Attention – switch attention between tasks or different info
Selective Attention – deliberately pick out info to attend to from other info
(Sohlberg & Mateer, 2010)

14. Types of memory
Short-term – hold info in mind to manipulate it (WM in some models)
Long-term – store of knowledge/memories - retrieve, pull into STM for use
Declarative – knowledge of info or events
---Semantic – knowledge anyone could find on Wikipedia
....“What’s the capital of Iceland?”..... “How many states in the US?”
---Episodic – knowledge particular to your experiences
....”What happened at the meeting?” ...”Who visited?”
Prospective – remember to do something later (e.g., stop by store)
Nondeclarative/implicit – skills, habits, implicit learning
---Procedural (e.g. ride bike, tie shoes)

15. Immediate & delayed TASKS – not types of memory
RBANS has immediate and delayed memory tasks
Immediate memory task – recall immediately after
Delayed memory task – recall after a delay
As SLPs, we want to help clients with memory tasks in real life – not just get better scores – so we focus treatment on compensatory strategies
Interpret test performance relative to routine function – connect to interview data

16. Addressing memory in treatment
Insufficient evidence for impairment-based approaches (e.g., drills)
Avoid stating or writing that you aim to “improve” memory
Evidence suggests compensatory memory strategies can be effective
Compensatory strategies:
External aids
Internal memory strategies
Environmental modifications
Communication partner training
Working memory can be targeted as a component of attention

17. Executive functions Initiation & drive - starting behavior
Response inhibition - stopping behavior
Task persistence - maintaining behavior
Organization - sequencing & timing behavior
Generative thinking - creativity, fluency, problem solving skills
Awareness - self evaluation & insight
(Sohlberg & Mateer, 2005)

18. Impact on Function, Activity and Participation
Symptoms can differentially impact routine function to varying degrees
--School attendance and performance
--Work attendance and performance
--Social involvement and social networks

19. Recognize symptom misattribution
Many factors can contribute to cognitive difficulties
mTBI
headaches, chronic pain
anxiety, depression, PTSD
sleep difficulties
substance use disorders
life stressors
Misattributing cognitive symptoms to a given cause can contribute to persistent symptoms
Focus on facilitating the recovery process
Create a context for working through difficulties and moving forward
(Clinician's Guide to Cognitive Rehabilitation in mTBI, 2016)

20. Finding Resources on InfoCDS
In response to past student feedback, we’ve made all of our procedures and expectations available on infoCDS.
We aim to be completely transparent and explicit with our instructions
Please ask for clarification if anything is unclear
You should read and be familiar with:
Supervisor expectations
BrICC Documentation Checklist
BrICC Report Writing – what works and what doesn’t
Rounds and consult materials
Intervention Selection Table

21. Locations of Key Resources on InfoCDS
“Assessment” page
Psychometric conversion table
“Student Preparation and Planning Materials” page
Rounds (instructions for rounds and portfolio)
Consults
Documentation (checklist; what works and what doesn’t)
Supervisor expectations
“Treatment Approaches and Intervention Materials” page
Intervention Selection Table

22. Consult templates in RDS
CDS > CDS Templates > BrICC > BrICC eval templates shortcut
Adult and Adolescent ABI cases
Adult neurodegenerative (use for Parkinson’s, Alzheimer’s, dementia, etc.)
Use Interview Guide on InfoCDS to make sure you are gathering all relevant information from the client
Use complete sentences, narrative format

23. Principles of Assessment
Client-centered
Identify functional impairments and impact
Use counseling skills (including but not limited to motivational interviewing)
Collaborative goal-setting (use GAS/eGAS)
Follow checklists/guides on infoCDS under Student Preparation and Planning Materials >Consults

24. Consultation Overview
Clinical interview (45 min)
Learn about presenting concerns, impact of sx on routine
Motivational interviewing + eGAS
Present possible treatment options to address concerns
Standardized battery/other protocols (1 hr, 15 min)
RBANS – every consult
TEA/TEA-Ch, BRIEF, D-KEFS, LASSI – as needed based on file review
PCSS, HIT – somatic sx after concussion

25. Template = A guide, not a rigid protocol
Adapt format, structure and components of templates as needed in consultation with supervisor

26. Standardized Batteries
RBANS
Refer to presentation titled ‘RBANS Update: Repeatable Battery for the Assessment of Neuropsychological Status’ by Anne-Marie Kimbell, PhD
TEA/ TEA-Ch – Versions A, B & C – begin with version A – administer full test
Course content – Management of Acquired Cognitive Disorders
BRIEF
LASSI
D-KEFS
Refer to training by Gloria Maccow, PhD

27. Types of Assessment Data
File review data
Clinical interview data
Behavioral observations
Standardized test scores
Questionnaire data

28. Types of scores Standard scores (M = 100, sd = 15)
Comparing performance to a standardized sample
Commonly used for comparing one person’s performance to others’
Scaled scores (M = 10, sd = 3)
Subtests often yield scaled scores
T scores (M = 50, sd = 10)
Determining clinical significance of a score
Z scores (M = 0, sd = 1)
Determining distance of a given score from the mean
(X – M)/s = Z (scores’s distance from the mean)

29. A handy reference
Psychometric Conversion Table
infoCDS > BrICC > Assessment

30. Practice calculating Z
Why?
Makes it easy to talk about a score’s distance from average
Useful for making it easier to compare
How?
You’ll need these numbers:
Score in question from a given distribution of scores
Mean of the distribution of scores in question
Standard deviation of of the given distribution in question
Use this formula: (X – M) /s = Z

31. General helpful principles
Draw simple graphics to talk about scores
Know the different types of scores possible
Read the scoring procedures in the manual
Read what the manual says about how to interpret scores
Consider everything you’ve learned so far about interpretation

32. Interpretation So much data, so little time! What does it all mean?
What hypotheses did you have at the start of the assessment?
Return to your hypotheses when interpreting data

33. Interpretation Interpretation should be based on hypothesis testing
Integrate data from multiple sources
Summarizing is useful and necessary, but insufficient
How are data consistent or inconsistent across sources (interview, testing, observation, etc.)?
For example - Does standardized testing data support interview data? Are data from the BRIEF consistent with test data and presenting concerns?

34. Treatment

35. Principles of Treatment
Recruit resilience
Cultivate therapeutic alliance
Acknowledge multifactorial complexities
Build a team
Focus on function
Promote realistic expectations for recovery
--Clinician's Guide to Cognitive Rehabilitation in mTBI (2016)

36. Treatment Options
Direct attention training combined with strategies (APT-3, AIM)
Functional skills training
Metacognitive strategy instruction
Training assistive technology for cognition (ATC)
External cognitive aids
Goal Management Training (GMT)
Personalized education
Environmental modifications/support

37. Treatment Selection Process
Consider
Client data - concerns, characteristics & desired outcomes
Evidence-based practice - refer to the literature
Expert knowledge - consult your supervisor
Ask
What is the rationale for selecting this approach for this client?
What barriers exist to implementing this treatment approach?
What will you measure to determine progress toward goals?
How will you take session data?
How will you measure progress toward the desired outcome?

38. Treatment Delivery Individual or group delivery options
Determine treatment approach in collaboration with your supervisor
Refer to infoCDS, BrICC “Treatment Approaches and Intervention Materials” > “bricc-intervention-selection-table_2016_final”
Individual or group delivery options
Consultation available with Center on Healthy Relationships (formerly CFT)

39. Center for Healthy Relationships
Consultation with
Center for Healthy Relationships
Consulting therapist may address psychosocial and emotional concerns for BrICC clients
Consulting therapist may attend individual sessions per client need and clinician request
BrICC clinicians report relevant observations and consult clinical supervisor prior to seeking consultation

40. *Immediate risk of harm = emergency = Call 911*
Crisis Management
When a client expresses suicidal thoughts...
Avoid expressing shock or alarm
Calmly talk to the person
Ask if they have a plan
Let it be OK to talk about it
Offer resources (next slide)
Notify supervisor as soon as feasible
*Immediate risk of harm = emergency = Call 911*

41. Resources for clients in crisis
For non-UO students
Crisis Intervention Line – White Bird Clinic (24 hours / 7 days)
(541) /
Campus resources for students
After-Hours Support and Crisis Line –
UO Counseling Center

42. Making efficient use of therapy time
We only have 6 weeks! Think back to last term—what if it had ended at week 6?
Start with goals and recommendations from last term. Try to narrow the focus to one achievable goal.
Make efficient use of time – remain focused

43. Measuring Progress
We often have two kinds of data for each client
In-session data (corresponds to STOs), e.g.:
Steps performed accurately during probe using systematic instruction
Time to complete task
Accuracy
Impact or generalization data, usually measured/tracked by the client or caregiver during the week (corresponds to LTG)

44. Your last session
Involve the next clinician if possible to facilitate a smooth transition
When sharing final progress with your client, take a collaborative approach
ask them what worked
how the strategies worked

45. Part 2

46. BrICC Student Expectations
How does BrICC differ from other clinics?
Rounds
Rounds portfolio
Focused self-reflections
Reflect on our changes to your documents
Consults
eGAS; interviewing and motivational interviewing; GAS

47. Timelines Lesson plans due 24 hours before the session
SOAPs and self-reflections due 24 hours after the session
Initial draft of Assessment Report due within a week of the consult
Initial draft of the ITP due: Monday July 17th (by midnight)- 1 goal and 1-2 objectives
Final ITPs due Monday August 7th (by midnight)– draft, and then you can put in final data later if you need to

48. Rounds Group supervision/clinical problem solving
Every week Tuesday at 3:00 starting on July 11th
Alex s presentation order beforehand – changes weekly
Oral case presentation + questions
Concise, complete oral reporting per template, with increased fluency as the term progresses

49. Goals and Competencies
Master professional communication and reporting skills to facilitate participation in medical rounds meetings
Further develop rational clinical decision making skills

50. Development of Skills Clinical Decision Making Reporting
“Clinical knowing”
Reporting
“Saying what you know”

51. Types of Reporting Case Introduction
Medical diagnosis (i.e. etiology)
Treatment diagnosis
Client/caregiver’s presenting concern
Previous history treatment
Treatment goal
Client Progress/Update Goal/Target
Approach
Measurement

52. Initial Case Introduction
Medical diagnosis (i.e. etiology)
Treatment diagnosis
Client/caregiver’s presenting concern
Previous history of treatment
Current outcome goal of therapy including
Goal
Approach
Desired Outcome

53. Initial Script Example
J is a 26 year-old male who presents with cognitive-communication deficits, including impairments in attention and working memory post- traumatic brain injury that resulted from a motor vehicle accident 6 months prior to his initial visit to BrICC.
J’s primary concern is his difficulty with attention and memory in terms of keeping up with the demands of his current job in office management.
J received 2 weeks of inpatient rehabilitation focused primarily on ADLs (activities of daily living). Treatment focused on orientation and introduction of memory strategies. This is J’s first term at BrICC.
Current goals for therapy including improving sustained attention and working memory though direct attention training in order to meet current job demands and decrease forgetting episodes at work.

54. Examples...and Non-examples
Mrs. Smith is a 73 year-old female, 6-months post left hemisphere CVA who presents with right hemiparesis and moderate non-fluent aphasia.
Mrs. Smith’s primary concern is her difficulty communicating wants and needs to her caregiver and initiating conversation with her grandchildren.
Mr. Jones experienced a severe traumatic brain injury resulting from an assault in May 2008.
What’s missing?
Neuropsych testing suggests deficits in sustained attention, speed of processing and new learning.
So what?

55. Initial Case Report Components
Medical diagnosis (i.e. etiology)
Treatment diagnosis
Client/caregiver’s presenting concern
Previous history of SLP

56. Good Questions Can you give a brief explanation of that treatment?
Can you describe that test/measure?
Why did you use X measure instead of Y measure ?
How are you measuring impact on daily life?

57. Update Script
This term we are focusing on (goal/target) through (approach).
Progress is being measured by (treatment measures) and (outcome measures).
Results suggest (outcome).
The plan is to…. .

58. Update Report Example
This term we are focusing on improving attention, working memory and recall of new information through direct process training (APT) and metacognitive strategy training targeting study skills.
Treatment progress is being measured by an increase in accuracy and decrease in response time on APT exercises and level of cueing required for study agenda generation. Impact progress is being measured by an increase in performance on the PASAT, an improved completion rate of classroom assignments/tests at a grade of B or higher, and self-report of improved focus while doing homework.
Results from our last session showed steady improvement in accuracy on APT accuracy but no change yet in speed of processing. Outcome measures show a 50% assignment completion rate increased from a baseline of 20%, with average grade of C. Self-report of homework focus was a 2 on a five point scale, with 1 being no focus and 5 being “stellar focus.”
The plan is to continue with APT exercises targeting alternating attention, to refine the homework set-up and self-monitoring .

59. Final Rounds Report
This term we focused on (goal/target) through (approach).
Progress was measured by (treatment measures) and (outcome measures).
Results suggested (outcome).
The plan is to…. .

60. Final Rounds Report Example
This term we focused on improving attention, working memory and recall of new information through direct process training (APT) and metacognitive strategy training targeting study skills.
Treatment progress was measured by an increase in accuracy and decrease in response time on APT exercises and level of cueing required for study agenda generation. Impact progress has been measured by an increase in performance on the PASAT, an improved completion rate of classroom assignments/tests at a grade of B or higher, and self-report of improved focus while doing homework.
Since this was M’s 7th week of APT exercises, the PASAT was re-administered and showed a 2 standard deviation improvement from the start of the term. Results from our last session showed an 90% homework completion rate with grade B or higher. This is M’s 3rd week at this level. M consistently reports a focus level of 4, and increase from 2 at the start of the term. However, M reports he often feels pressure to stop studying to complete home chores. He states he starts and stops chores, losing track of what’s been done, and that this is an area he would like to improve.
As M’s LTG targeting study skills has been met, the plan is to discontinue APT exercises and study strategy training. M would like to start a new LTG related to completing home tasks which will be targeted via goal management training.

61. Supervision
Combination of group supervision (rounds/training sessions) and individual, mostly by
If there are complex client needs or complex personal issues, you may us to schedule an individual meeting
No midterm meetings unless there is a concern
Self-reflections
Summary of changes to show what you learned from our edits to your documents
You don’t need to complete a written CHARTR, but be familiar with the process and ready to provide a rationale for clinical decision-making if asked

62. Documentation Expectations:
Reflect your knowledge of cognitive domains and principles of cognitive rehabilitation
Detail-oriented, professional work
Use complete sentences and narrative descriptions in consult reports
See examples in RDS, e.g. MCJO
Proofread, spell-check and grammar check your work

63. Self-reflections After each session Due within 24 hours
Reflect on your own clinical performance
Consider our feedback carefully and respond
Supervisors may specific reflection questions
If we don’t send specific reflection questions, respond to the following two questions: (1) What did you do that made the session go well, and how did you know it had a positive effect? (2) What would you like to do differently in hindsight, and how will you know if this works?

64. Rounds Portfolio
Instructions are in InfoCDS > BrICC > Student Preparation and Planning Materials
Purpose:
focus your attention and maximize learning during rounds
Showcase your knowledge and exposure to a variety of cases when interviewing for jobs or externships
Future reference for you to look back on if you have a similar client
Update it during each time at rounds
it to your supervisor at the end of the term
Must complete to pass clinic

65. Using good counseling skills
Open-ended questions
increase collaboration, elicit “change talk”
Affirmations
Denote empathy, increase motivation
Reflections
Simple: denote empathy
Complex: increase motivation to change, self-awareness, emphasize partnership
Summary
emphasize partnership and acknowledge client’s awareness

66. “When you head out to sea in your little boat, don’t forget your OARS”
Remember Your OARS
“When you head out to sea in your little boat, don’t forget your OARS”
Open-ended questions
Affirmations
Reflections
Summary
Review notes from Cog Rehab class, MI handout, and eGAS to see examples of each

67. eGAS: Electronic Goal Attainment Scaling
Motivational interviewing: A collaborative, interviewing technique used to increase motivation, facilitate “change talk”, and elicit goals while promoting client autonomy.
Goal Attainment Scaling: An approach that helps quantify personally relevant goals

68. Registering a client on eGAS

69. Each iPad should have a number on it
Each iPad should have a number on it. Take note of the number your client is registered on; when you come back to that iPad later, you can use “Select a Client” (top option) to select your client from the dropdown menu.

70. Communication Be in touch about your needs
Tell us what helps you learn
Propose plans and seek feedback
Respond to s promptly
Notify of schedule changes, cancellations
Copy supervisor in all case-related communications

71. Learning Objectives Checkpoint
Describe the purpose of BrICC and characteristics of client populations.
Identify special features of the BriCC clinic experience that may be different from other specialty clinics.
Describe components of an initial cognitive consultation and how to prepare.
Explain guiding principles of treatment selection and delivery in BrICC.
Locate checklists, instructions, and templates on infoCDS and RDS to assist you in preparing for rounds, consults, treatment, and completing required documentation.
Make sure that you ask about anything that is unclear, and feel comfortable contacting your supervisor (Alex or Heidi) by to clarify any further questions that come up.

72. References
Clinician's Guide to Cognitive Rehabilitation in Mild TBI: Application in Military Service Members and Veterans (In submission).  Rehabilitation and Reintegration Division, Office of the Surgeon General, United States Army.
Sohlberg, M. M. & Ledbetter, A. K. (2016). Management of Persistent Cognitive Symptoms After Sport-Related Concussion. American Journal of Speech-Language Pathology, 25, DOI: /2015_AJSLP
Sohlberg, M. M., & Mateer, C. A. (2001). Cognitive rehabilitation: An integrative neuropsychological approach. New York: Guilford Press.
Sohlberg, M. M., & Turkstra, L. S. (2011). Optimizing cognitive rehabilitation. New York: Guilford Press.

73. Gots & Needs
Let us know if you’d appreciate further training sessions on certain topics, and we will schedule those when Alex comes back.
ITP/goal writing?
GAS?
How to have a discussion about dismissing a client?
Redirecting clients who have trouble staying on-topic?