BrICC Brain Injury & Concussion Clinic CLINICIAN TRAINING

BrICC Brain Injury & Concussion Clinic CLINICIAN TRAINING
Fall 2016 Communication Disorders & Sciences University of Oregon

Today’s schedule Welcome! ....Quick introductions – 1 minute
Mentors and apprentices explained – 4 minutes Training Part 1 – 40 minutes Quick break – 5 minutes Training Part 2 – 50 minutes Questions, clarifications, planning, scheduling meetings – 20 minutes

Training Overview PART 1 Clinic Purpose & Populations PART 2
Initial Cognitive Consultations Motivational Interviewing & eGAS Administering Assessments Treatment Selection Scoring Assessments Writing Effective SOAPs Basic Stats & Types of Scores Documentation & Timelines Interpreting Assessment Data Rounds & Supervision Questions? Orientation to Resources

Learning Objectives By the end of today’s training, you should be able to…. Describe purpose of BrICC and characteristics of client populations. Describe components of an initial cognitive consultation and how to prepare. Differentiate among types of scores, explain what a standard deviation means, and know how to derive a Z score. Consider data from multiple sources to inform treatment selection. Express the purpose of motivational interviewing and demonstrate a working knowledge of how to set up goal attainment scaling using eGAS. Express several considerations and questions relevant to treatment selection and offer an example of a clinical rationale for selecting a given treatment for a client. Access relevant resources to support your work and prepare for weekly rounds.

Part 1

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

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

Populations

Populations 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

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

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

Cognitive domains addressed in BrICC
Attention Memory Executive Function

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 different info Selective Attention – deliberately pick out info to attend to from other info (Sohlberg & Mateer, 2010)

Memory Short-term memory – holding info in mind to do something with it, synonymous with working memory (a component of attention) in some models Long-term memory – store of knowledge/memories, can retrieve and pull into STM for use Declarative memory – knowledge of info or events ---Semantic memory – knowledge common to all, e.g. what you could find on Wikipedia .....“What’s the capital of Oregon?”..... “Who is the US president?” ---Episodic memory - knowledge particular to your experiences, e.g. memory of a birthday ....”What did you do this morning?” ....”What happened at the meeting?”  Semantic and episodic memory may influence each other Prospective memory – remembering to do something in the future, like stop by the store Nondeclarative/implicit memory – skills, habits, implicit learning ---Procedural memory e.g. remembering how to ride a bike or tie shoes)

Clarification of terms
Although the RBANS has test sections called “Immediate Memory” and “Delayed Memory,” please note that these are not types of memory Immediate memory is a testing procedure whereby you ask someone to recall something immediately after they heard it. Delayed memory is a testing procedure whereby you ask someone to recall something after a delay. As SLPs, we don’t target “immediate memory” and “delayed memory”—we want our clients to perform well in memory tasks in real life, not just to get better scores on a test!

Addressing memory in treatment
There is insufficient evidence that impairment-based approaches such as “memory drills” or “memory practice” improve memory Therefore, avoid stating in your documentation that you aim to “improve” someone’s memory Evidence suggests that compensatory strategies for memory 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

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)

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

Be aware of symptom misattribution
"[I]t is important to recognize and appreciate the multifactorial nature of symptoms in [those seeking] treatment. Cognitive difficulties .....[can be] due to a variety of contributory factors including mTBI, chronic pain, headaches, PTSD, depression, anxiety, sleep difficulties, substance use disorders, and life stressors. While it is normal for both [clients] and clinicians to want to attribute cognitive symptoms to one cause or etiology (e.g., attributing aphasia or neglect to a stroke), such misattributions can actually be harmful or lead to the persistence of symptoms in many individuals. By recognizing the complexity of the originating condition, the clinician creates a more nuanced context for working through the difficulties [with which clients present] and facilitates the recovery process.” --Clinician's Guide to Cognitive Rehabilitation in mTBI, 2016, p. 2 (emphasis added)

Initial Cognitive Consultation

Consultation Schedule
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

Consultation Preparation: Resources
infoCDS > Specialty Clinics > BrICC RDS > BrICC Clinic > Assessment templates Procedural information Forms Test protocols PCSS and HIT (concussion cases)

Template = A guide, not a rigid protocol
Adult – 18 and older – any life context Post-secondary – 18 and older – college or training Adolescent – 18 and younger – still in HS Adapt format, structure and components of templates as needed in consultation with supervisor

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

Basic Stats & Types of Scores

Section Overview Types of scores & relationships among them
Describing and comparing types of scores Interpretation of scores relative to other data

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)

Google this now “Psychometric Conversion Chart” Download it Keep it handy Makes a very useful reference!

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 Let’s do a few on the board now

General helpful principles
Draw simple graphics to talk about scores (demo) 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

Assessment Interpretation

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

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

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?

Treatment Selection

Several Treatment Options
ATC/External aid training Direct attention training Metacognitive strategy instruction Goal Management Training Functional skills training Personalized education Environmental modifications/support Informative table available next week!

Treatment Selection Consider and evaluate from several angles
Assessment data from multiple sources Client data - concerns, characteristics & desired outcomes Values, preferences and priorities of the client Evidence-based practice - refer to the literature Expert knowledge - consult your supervisor

Treatment Selection Ask yourself...
What is my rationale for selecting this approach for this client? What do I know about this client’s presenting concerns, assessment profile, and desired outcomes and other characteristics (e.g., awareness, expressed interest in tx, social/emotional needs, support system)? What barriers exist to implementing this approach? What other approaches might be viable? Why? What approaches are not suitable? Why?

Treatment Selection Modify or adjust the approach when necessary
Collect session data What will you measure to determine progress toward goals? How will you take session data? How will you measure progress toward the desired outcome? Is the approach working? Are there barriers to progress?

Questions?

Part 2

Motivational Interviewing
Today I will be talking about Motivational Interviewing, Goal Attainment Scaling and the eGas app. I based some of this presentation on the slides created by Priya for the BRICC clinic orientation last quarter, but I updated and reorganized it for this quarter. Ask a student to define motivational interviewing based on learning about it in McKay’s class last quarter Ask if any students have had experience in MI, and to briefly describe their experience

Motivational Interviewing
Combines interviewing and counseling techniques Grounded in principles of collaboration and client autonomy Elicits “change talk” in client and increases readiness to change Benefits: Increases motivation, client buy-in, and rapport Facilitates selection of goals that have larger impact for the client Why might motivational interviewing be especially important for BrICC clients? It can be difficult for patients with brain injury to generate goals that are related to particular cognitive impairments, and the interviewing techniques can facilitate goal formulation

Principles of Motivational Interviewing
“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

How to Prepare for Motivational Interviewing
Take some time to become familiar with the eGAS app in advance When reviewing the chart and planning the first session/consult, identify Relevant clinical questions--areas to gather information about Possible motivational interview questions (can refer to eGAS app and/or MI handout) How you will respond to their answers by affirming, reflecting, and summarizing based on what they say

Cog Eval Form vs. MI: A Trap to Avoid
Many yes/no check boxes on the “Adult Cognitive Evaluation” form However, you do not need to ask questions that way! Demonstrate your knowledge, insight, and sensitivity in how you phrase the questions & respond to the client’s answers. This is skilled assessment; simply asking yes/no questions as written then moving on to the next is not. Use open-ended questions as much as possible When you do use yes/no questions, follow up when appropriate by reflecting and/or asking follow-up questions The “Adult Cognitive Evaluation” form we use as an assessment report template in BrICC contains many yes/no check boxes. Often, clinicians simply ask yes/no questions to get all the information on this form. After hearing each answer, they write it down and go on to the next. However, this is not motivational interviewing, nor is it skilled assessment. We expect you to demonstrate your knowledge, judgement, and sensitivity in how you phrase the questions and how you respond to the client’s answers verbally. In some cases, you can continue to use open-ended questions to find the answers to these by having the client talk freely about their symptoms and concerns.

What is your role? During the MI portion of the consult, the student’s role is to start out the MI by asking broad questions to get at the root of the concern, such as “What brings you here today?” The student will continue to take the lead in the MI as long as they can, using all components of OARS At the same time, the student is taking notes, preferably on eGAS When necessary, the supervisor will jump in and ask follow-up questions to clarify and fill in missing information

Pairwork Activity: Motivational Interviewing
Think of a personal goal you don’t mind sharing. Something you want to try to do more often or less often works well E.g. exercise or practice an instrument/language more times a week? Find a partner Open the eGAS app to see example MI questions & scripts Practice motivational interviewing with your partner using your selected goal. Try to elicit “change talk” in your partner.

eGAS Developed by Dr. Sohlberg & team
Combines MI and goal attainment scaling (GAS) Provides a client-centered, individualized outcome measure that can be measured objectively iPads with eGAS are available for checkout in the GTF office Complete eGAS for your client during the cognitive consult or during the first two sessions, if not a new consult

Registering a client (use client CODE)

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.

eGAS: Starting the interview MI Prompts
The text in green is questions or scripts you can say directly to the client. The text in red is instructions to you about how to proceed. Note that there are different stages of the interview, “Problem identification,” “Buy-in,” “Strategy selection”, and “Completing the GAS”. Clicking on each heading opens up a different page of scripts and instructions. .

eGAS: Inputting responses
Find the blue button on the upper right: this is the “Scratchpad”. It is a notepad for taking notes. You can access it at any time. Clinician takes notes on scratchpad initially… Clinician might ask a continuation question…then she might summarize or reflect (paraphrase – simple) Eventually Jill was asked – if you could resolve one of your concerns, which one would have the biggest impact on your life? Jill stated – I think the ability to maintain my social relationships with family / friends, through other means of communication – like texting. That’s what I was learning to do before I had my TBI – This info belongs to the functional feature domain

E eGAS – Inputting Responses
The green buttons on the right side of the screen have different areas to fill out depending on what your client says. These can be completed out of order. Select a functional goal domain- what kind of functional activity is this goal related to?

eGAS : Activity and Context
Activity – specific task that the client wishes to accomplish Context – where will they do this activity, what persons/supports will be available to facilitate this activity, what obstacles or issues are involved in this activity

eGAS: Underlying Cognitive Domain; Therapy Approaches
The underlying cognitive domain is the area of impairment, e.g. memory, executive functioning, etc. Use information from interview and testing Therapy Approaches – intervention approaches

Goal Attainment Scaling (GAS)
Outcome measure Individualized Objective Criterion-referenced Uses a 5-point scale Values range from 2 (most favorable) to -2 (least favorable) Can obtain standardized scores such as T-scores to analyze results across clients

Example of GAS Goal Attainment Scale Level of Outcome Rating
Statement of Outcome Much more than expected +2 Jayne will complete 4+ assignments/readings in 1 week More than expected +1 Jayne will complete 3 assignments/readings in 1 week Expected outcome Jayne will complete 2 assignments/readings in 1 week Less than expected -1 Jayne will complete 1 assignment/reading in 1 week Much less than expected -2 Jayne will complete 0 assignments/readings in 1 week

Key Components - SMARTED Scale
Specific Measurable Attainable Relevant Time-specific Equidistant uniDimensional

Your Example – Let’s Make a GAS
Level of Outcome Rating Statement of Outcome Much more than expected +2 More than expected +1 Expected outcome Less than expected (Baseline) -1 Much less than expected -2

Steps for creating a GAS
Define levels – refer to script questions e.g. “What might it look like if this problem completely went away?” How can we make this measurable? Check whether scale meets ALL GAS criteria Can be modified later Weight the goals – which are more important to the client? Define measurement – how will we measure progress on this goal?

eGAS – what is your role? Before the session During the session
Register the client code in eGAS Be familiar with the green buttons on the right side of the screen Practice using the app to enter information During the session Use the dropdown menus and record information in the relevant categories Create the GAS – goal is to complete in first 1-2 sessions After the session Integrate the information gathered into your assessment report or ITP Include the GAS in your SOAP, initial and final ITP

Treatment

Treatment Options Direct attention training Functional skills training
Metacognitive strategy instruction Training assistive technology for cognition (ATC) External cognitive aids Goal Management Training (GMT) Personalized education Environmental modifications/support

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?

Treatment Delivery Determine treatment direction
Individual or group delivery options Consultation available with Center on Healthy Relationships (formerly CFT)

6 Guiding Principles for the Treatment Process
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)

Interdisciplinary Collaboration

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

Crisis Management

*Immediate risk of harm = emergency = Call 911*
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*

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

Documentation

Writing Effective SOAPs for BrICC
Heidi Iwashita, M.S., CCC-SLP Updated Summer 2016

Overview Subjective Objective Analysis Plan

You have learned those terms, but…
What do supervisors expect me to put in each section? Why is it organized this way? Why do I keep getting my SOAPs back with lots of edits? How much is too much information? Too little? What is the rationale for including the information we do include?

Why do SOAPs? The SOAP provides a concise record of services provided on that day Although the format may vary, as practicing SLPs you will have to document that you used therapy time appropriately “Appropriately” means that time was spent working on goals that are individualized for the client and lead to functional cognitive/communicative outcomes

What makes a good SOAP This presentation will provide some guidance and tips for each section As supervisors, our feedback is meant to teach you to write accurate, informative SOAPs similar to the ones that will be required if you work in an adult rehabilitation/medical setting A good SOAP should be: Truthful Complete Unambiguous These tips are not exhaustive. If you have another tip that you think might help future students, please share it!

S: Section

SOAP Notes – S: section – General Tips
Who else is there? Who said what? Attributing statements correctly “Reported” “Noted” “Stated” “The client seemed in a good mood” vs. “the client was in a good mood.” Generally keep the S: section short. However, if there were complicated or serious issues, document that you followed up correctly.

SOAP Notes – S: section – General Tips
Most importantly, in the S: section, CAP Clarify any ambiguities Attribute statements correctly Put our minds at ease – don’t make us worry unnecessarily about the client! If there was cause for concern, how did you address that?

SOAP Note examples – S: Section
When there is something out of the ordinary reported by the client S: TTT and his mother, Mrs. T, arrived ten minutes late to his scheduled appointment. His mother reported that TTT experienced significant pain in his foot over the break, but is now doing “much better.” S: OOO reported that she was diagnosed with type II diabetes during the past week, and it has been “very stressful” for her.

When there is nothing out of the ordinary, what would that look like?

S: RRR arrived to today’s session on time with her husband Mr. R, who stayed in the lobby. RRR seemed to be in good spirits and readily engaged in conversation with the clinician and the clinical supervisor for the entire session.

What concerns do you have reading this S: section? S: QQQ reported that, since her stroke, she always feels “stuffed up to [her] neck.” She, therefore, does not eat during the day. QQQ expressed desire to meet with a neurologist. QQQ and her partner, Mr. Q, talked about her Obsessive-Compulsive Disorder (OCD). Mr. Q joined QQQ in the session.

S: QQQ reported that, since her stroke, she always feels “stuffed up to [her] neck.” She, therefore, does not eat during the day but does not report having difficulties with swallowing. In response to follow-up questions by the clinician, she clarified that she has not lost weight, that she eats at night, and that she takes a multivitamin. QQQ expressed desire to meet with a neurologist, and the clinician told her she would look into a referral. QQQ and her partner, Mr. Q, also reported that she displays symptoms of Obsessive-Compulsive Disorder (OCD), but she has not been formally diagnosed with the disorder. Mr. Q joined QQQ in the session.

O: Section

With Tables Tables are nice if you have quantitative data
It’s good to include previous scores for comparison when you can Dates should go across the top, not down to the side, with the most recent date on the right If you use codes like “M” “C”, “+”, etc., be sure to include a key at the bottom of the table designating what these mean

Without Tables Sometimes your data is more qualitative in nature and does not fit easily into tables, e.g. information gained from motivational interviewing If you have a lot of different areas to cover in sentence form, consider breaking it up into subsections with headers in bold Summarize concisely and objectively Focus on information relevant to setting goals (when assessing) and achieving goals that have been set

A: Section

SOAP Notes – A: Section – Philosophy
“The SOAPs are like chapters of a book and each term is a volume of the book, telling the story of that person.” – Alex Ledbetter “The ‘why’ of the O” – Susan Boettcher While the self-reflection is about what you could do differently as a clinician next time, the A section is about what the client needs to do better next time. Do they need more support, different types of tasks, more motivation? Some of the same areas of difficulty that came up in your self-reflection may come up in your A section, but this time you are framing it with a focus on the client rather than on you.

What to Include in the A: Section
Client response to the intervention Reasons/explanations for the client’s performance What to change (if applicable) based on the client’s performance today

CREW Client response Reasons/ Explanations What to change

SOAP Notes – A: Section – General Tips
Don’t repeat information already in your O: section Make sure it follows logically from your data and what you observed in the session; it should not be speculation coming out of nowhere. It should progress logically from the O: section and into your P: section. So if you identified some ways to adjust your treatment based on the client’s performance today, you would explain that in the A: section, and include your steps for following up on that in your P: section. It should include the client’s response to your intervention. Insurance providers are now looking for that as evidence that therapists are actually providing a skilled service by customizing therapy tasks to the individual.

Let’s look at some examples.
In each example, identify: Client response Reasons/explanations What to change (if applicable).

A: Compared to the previous session, YYY required less intensive cueing to place his fingers on the home row keys. However, he experienced more difficulty with limiting the keys pressed to the target keys. This may have been a result of the change in computer or associated with his reduced fine motor control, reported by his mother, since the SMART attack. Similarly, the accuracy that YYY achieved on the AIM drill may have been affected by the change in computer or difficulty with fine motor control. It will be useful to assess YYY’s performance on these tasks using the normal computer during the next session. It may also be useful to have YYY try to use an external mouse (rather than the buttons on a laptop mousepad) to complete the AIM drills. YYY’s lack of strategy use during the AIM drill suggests that more time should be spent evaluating the strategy that is best-suited for him, and giving him concrete examples.

Red- client response Blue – reasons for client’s performance Green – how to adjust tasks
A: Compared to the previous session, YYY required less intensive cueing to place his fingers on the home row keys. However, he experienced more difficulty with limiting the keys pressed to the target keys. This may have been a result of the change in computer or associated with his reduced fine motor control, reported by his mother, since the SMART attack. Similarly, the accuracy that YYY achieved on the AIM drill may have been affected by the change in computer or difficulty with fine motor control. It will be useful to assess YYY’s performance on these tasks using the normal computer during the next session. It may also be useful to have YYY try to use an external mouse (rather than the buttons on a laptop mousepad) to complete the AIM drills. YYY’s lack of strategy use during the AIM drill suggests that more time should be spent evaluating the strategy that is best-suited for him, and giving him concrete examples.

A: Though LLL could not initially recall the order and Step One of the strategy introduced during the previous session, she seemed to benefit from the use of visual supports (a form that could be filled in, and steps written on a white board) and the clinician’s verbal prompts. Throughout the session, LLL’s functional understanding of the strategy seemed to increase from having the opportunity to restate descriptions of each of the steps in her own words. By the end of the session, LLL was able to apply all three steps of the strategy to hypothetical situations through the use of diminishing cues and mass practice. While LLL had difficulty independently determining in which situations she could use the strategy outside the clinic, she responded well to the clinician’s direct instruction and agreed to use the strategy when riding in the car to and from the clinic this week.

Red- client response Blue – reasons for client’s performance Green – plan for the future
A: Though LLL could not initially recall the order and Step One of the strategy introduced during the previous session, she seemed to benefit from the use of visual supports (a form that could be filled in, and steps written on a white board) and the clinician’s verbal prompts. Throughout the session, LLL’s functional understanding of the strategy seemed to increase from having the opportunity to restate descriptions of each of the steps in her own words. By the end of the session, LLL was able to apply all three steps of the strategy to hypothetical situations through the use of diminishing cues and mass practice. While LLL had difficulty independently determining in which situations she could use the strategy outside the clinic, she responded well to the clinician’s direct instruction and agreed to use the strategy when riding in the car to and from the clinic this week.

A: Based on a rating of at least 4 on PPP’s homework assignments, it was to be concluded that she can accurately follow complex instructions, write concisely, and alternate attention in a functional setting. However, because she was unclear about the “Writing Concisely” rating scale, more data should be obtained. Based on the results of the BRIEF-A, PPP does not demonstrate clinically significant deficits in executive functioning. Considering her performance on assessments, on therapy tasks in the clinic, and on homework tasks, PPP may not benefit from further speech and language services, and dismissal should be considered.

A: SSS continued to demonstrate increased self-efficacy during today’s session. She effectively restated the strategies in her own words and used analogies to describe them (e.g. “The steps are like my self-itinerary.”) Statements like these, as well as her increased use of the strategy tracking chart throughout the week, represent SSS’s increased understanding and ability to generalize the strategy to functional situations. SSS also identified that “breathing” (step 2) and “choosing a focus” (step 3) are “controllers” that she can “apply to triggers” when feeling overwhelmed. While SSS had a high level of independent success when applying her strategy to clinician-generated situations, she had greater difficulty remembering to implement them while using APT-3 as a generalization task. This may be attributed to her previous experience with APT-3, in which she was focused on completing the task to the best of her ability, and not on the explicit use of metacognitive strategies. SSS endorsed the clinician’s recommendation of practicing her strategy outside of the clinic room in the upcoming sessions, stating that although it “scares” her, it would be “worth trying.”

A: MMM’s successful performance during each step of the visual schedule indicates that he is capable of using an aid of this type. It will be helpful for the clinician to select one keyword (e.g. “finished”) to use as a verbal prompt during subsequent training of the visual schedule. MMM’s performance on the memory book activity suggests that it may be beneficial to focus on how to use the book, rather than focusing on his knowledge of the book itself (e.g. name, purpose). Altering the steps to include more functional ways to use the book during conversations (e.g. how to comment and ask questions about the topics) will be necessary for MMM to use the book during everyday life.

P: Section

P: Section Can be in the form of a numbered list
List items should naturally follow from issues raised in the S: or A: sections Any modifications to current approach? New approaches to consider? Follow ups? “Continue [current approach]” if it is working

Main Ideas S: section – CAP Clarify any ambiguities
Attribute statements correctly Put our minds at ease In the A: section, include CREW Client response Reasons/explanations What to change

Documentation & Timelines
Initial Consultation Reports Arrange due date with supervisor SOAPs 24-hour turnaround Self-Reflection ITP/Progress Summary

Rounds & Supervision

Rounds Group supervision Clinical problem solving
Every week TU 4:00-5:00pm Oral case presentation + questions Expectation = concise, complete oral reporting per template, with increased fluency as the term progresses

Oral Case Reporting Templates & Sample Scripts

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

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

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

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

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.

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?

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

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?

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…. .

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 .

Final 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…. .

Final 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.

Clinical Supervision Meet for individual supervision as needed
Arrange by Amount/frequency vary – support fades as skills grow ---2nd year clinicians – supervisor takes on consultative role ---1st year clinicians – supervisor fades supports as your skills emerge

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

Next Steps Complete follow-up readings Review client files
Formulate clinical questions Consider treatment options carefully Determine a plan of action Prepare initial oral case report Present your plan to supervisor

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.

BrICC Brain Injury & Concussion Clinic CLINICIAN TRAINING

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BrICC Brain Injury & Concussion Clinic CLINICIAN TRAINING

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