1. Key Elements for Implementation Life Participation Approach to Aphasia
NOTE: The associated document, “Life Participation Approach to Aphasia”, contains information regarding relevant standards/guidelines, learning objectives, additional learning materials, and assessment activities. The document “Summary of Research References” contains the references separated into categories © 2017 Aphasia Access

2. Academic Module Sponsors

3. Academic Module Committee

4. About Aphasia Access Received its 501c(3) designation in May 2014
Membership includes representation from 33 states and 5 Canadian Provinces. The Life Participation Approach to Aphasia (LPAA) is the core philosophy.
Produces videos, webinars and podcasts that are used internationally to educate speech-language pathologists, healthcare professionals, students, nonprofit board members and community leaders.
Advocates for aphasia care and communication access throughout health care.

5. Target Audience
This presentation has been developed for speech-language pathology (SLP) students and current practitioners.

6. Learning Objectives
Upon successful completion of this learning module, participants will be able to:
Distinguish key elements in the implementation of LPAA model
Identify how LPAA augments/extends impairment based treatment
Construct a therapeutic environment that encompasses the LPAA model for PWA

7. LPAA Curriculum Modules
The Working Group on Academic Curricular of the Education and Research Committee of AphasiaAccess has developed this module to
Address how LPAA principles differ from and complement a traditional impairment-based approach for the intervention for PWA.

8. Life Participation Approach to Aphasia
LPAA is a:
Person-centered service delivery model,
Supports PWA and others affected by it, and
Helps them achieve their life goals.
The LPAA philosophy seeks to impact a person’s quality of life.
The goal is re-engagement in life!

9. Life Participation Approach to Aphasia
LPAA places life concerns of PWA at the center of all decisions.
The clinician strengthens daily participation in activities of the client’s choice.
The clinician not only works on communication but also on establishing and maintaining social links… for it is within this environment that one communicates.

10. Life Participation Approach to Aphasia
Mission: Minimize the effects of life barriers for all persons (including the stroke survivor with aphasia, family and close friends) connected to this ongoing shift in life.
Emphasis is on adjusting feelings/attitudes about self and others.
Focus is on strengthening intra-personal and inter-personal communication and increasing participation in activities of choice.

11. The Focus of LPAA
Empowering persons with aphasia to become active agents in determining their direction and involvement in daily life.
KEY FACTORS ARE:
Client driven goals
Personal choice of activities and level of participation
Engagement of significant others in therapy
Expansion of therapeutic settings to include real-life situations and dilemmas

12. Research Supporting Need for LPAA
Operationally, how does one incorporate LPAA into practice and how does it differ from traditional impairment-based therapy?

13. FRAMEWORK FOR OUTCOMES MEASUREMENT
(A-FROM)
Living with Aphasia
Aphasia Institute, Kagan, Simmons-Mackie, Rowland, et.al. 2008
The Living with Aphasia-Framework for Outcomes Measurement is an innovative way of looking at providing services to persons with aphasia that follow the Life Participation Approach to Aphasia philosophy.
The ideas described in this approach can also be helpful in thinking about social models of dementia management.
This model puts the person with the communication disorder at the center, and allows us to think about the personal and environmental factors, as well as disorder severity, that impact the person’s ability to engage in meaningful daily life.

14. Services need to address real-life participation Context is key
How can A-FROM help us think about services for persons with aphasia or a cognitive-linguistic disorder?
Services need to address real-life participation
Context is key
Personal factors
Physical and social factors
Increasing successful participation in authentic contexts/communication events
Providing communicative support systems within the speaker’s community
The Living with Aphasia-Framework for Outcomes Measurement is an innovative way of looking at providing services to persons with aphasia that follow the Life Participation Approach to Aphasia philosophy.
The ideas described in this approach can also be helpful in thinking about social models of dementia management.
This model puts the person with the communication disorder at the center, and allows us to think about the personal and environmental factors, as well as disorder severity, that impact the person’s ability to engage in meaningful daily life.

15. Overview for Users
This presentation will identify the following elements, both within the LPAA model and a traditional impairment-based model of treatment
Outcomes
Assessment
Persons treated
Treatment
Environment
Therapists’ role

16. Research Supporting Need for LPAA
Before looking at each,
let’s set the stage.

17. Premises for LPAA are to:
Increase access while reducing barriers in healthcare,
Facilitate participation in personally relevant activities, and
Create a sense of fulfillment in one’s life.

18. OUTCOMES Research Supporting Need for LPAA Taking at look at
Beginning with the end… Looking at desired outcomes first

19. Improvement in skills related to:
What kinds of outcomes can be expected when designing impairment-based intervention?
Improvement in skills related to:
word recall
auditory comprehension
discourse (verbal and written)
reading
grammar
writing
speech intelligibility

20. Increased behaviors as measured by
What kinds of outcomes can be expected when designing LPAA intervention?
Increased behaviors as measured by
Engagement
Social connectedness
Satisfaction of self-chosen activities
Emotional well-being
Ability to cope, resiliency
Natural conversation or communication

21. Client may be observed to have
What kinds of outcomes can be expected when designing LPAA intervention?
Client may be observed to have
New discovery of self and others
New skills and activities
New relationships
New meaning in life
Renewed energy

22. Research Supporting Need for LPAA
Taking at look at
ASSESSMENTS

23. Western Aphasia Battery (WAB)
What assessments are likely given in an impairment-based evaluation?
Western Aphasia Battery (WAB)
Boston Diagnostic Aphasia Examination (BDAE)
Reading Comprehension Battery for Aphasia (RCBA)
Aphasia Diagnostic Profiles (ADP)

24. LPAA: Change in Assessment
Focus is on “re-engagement in life.”
Discovering competencies
Evaluating support systems
Assessing client’s chosen activities to re-engage and help determine their level of participation.
Assessing life participation barriers and life participation facilitators

25. What assessments are likely given in an LPAA-based evaluation
What assessments are likely given in an LPAA-based evaluation? (Alphabetical Order)
ASHA Quality of Communication Life Scale (ASHA QCL; Paul-Brown et al. 2004)
Aphasia Communication Outcome Measure (ACOM; Hula et al. 2015)
Assessment for Living with Aphasia (ALA; Kagan et al. 2010)
Communication Confidence Rating Scale for Aphasia (CCRSA; Cherney et al. 2011)

26. What assessments are likely given in an LPAA-based evaluation
What assessments are likely given in an LPAA-based evaluation? (Alphabetical Order)
Communication Effectiveness Index (Lomas et al. 1989)
Community Integration Questionnaire (with or without pictographs) (CIQ; Willer et al. 1993)
Stroke and Aphasia Quality Of Life Scale – 39 (SAQOL-39; Hilari et al. 2003)
The Burden of Stroke Scale (BOSS; Doyle et al. 2003)
Visual Analogue Mood Scales (VAMS; Stern; 1997)

27. Role of Narrative as Part of a Holistic Approach to Assessment in LPAA Model
Shadden, B. (2007) “The Role of Narrative in the Life Participation Approach to Aphasia.” Topics in Language Disorders, Volume 27(4), pp
Engage client in telling personal, health and/or stroke narratives
Suggests McAdams et al.’s (2006) Life Story interview as a possible means for assessment

28. Examples of Additional Questions
What do we know about the dyadic communication within the home of our clients?
Are our clients valued and connected with those people they care the most about?
Have our couples learned to quickly avoid or ignore conversational realms and/or topics?
Are they engaged with each other in a variety of life situations?
Are our clients personally, socially and comfortably connected in life?

29. GOALS FOR TREATMENT Research Supporting Need for LPAA
Taking at look at
GOALS FOR
TREATMENT

30. What goals are likely to be written for impairment-based therapy?
The clinician designs goals based on what are viewed as impairments in speech/language/cognition.
The clinician works on improving and/or compensating for speech/language/cognitive loss.

31. What goals are likely to be written for impairment-based therapy?
Goals are largely quantitative; explicit behaviors observed and tallied.
Goals take the format of an observed behavior (action), that is measurable to a certain achievable level.
These behaviors may be discrete language behaviors (e.g., naming a picture) or functional tasks (e.g., writing a list).

32. What goals are likely to be written in an LPAA-based therapeutic environment?
The clinician writes client driven goals that address anything where aphasia is a barrier to life participation.

33. Goals shift to engaging in self-chosen daily life activities
What goals are likely to be written for LPAA-based therapy?
Goals shift to engaging in self-chosen daily life activities
Goals are for client to demonstrate level of participation in self-chosen activity.
Goals are to work toward acceptance of life’s differences with aphasia
Goals may lead to discovery of unexpected value or merit in life after stroke with aphasia.

34. Research Supporting Need for LPAA
Let’s take a closer look at
GOALS

35. Education as to what happened Understanding of safety precautions
In the acute setting, a client’s goals may focus on the following:
Education as to what happened
Understanding of safety precautions
Ability to call for help
Ability to compliment/complain
Ability to answer biographical information
Selection of menu
Ability to give personal health status
Participation in discharge planning

36. Impairment-based and participation-based goals in an acute setting
LONG TERM GOAL Client will participate in discharge planning.
IMPAIRMENT-BASED SHORT TERM GOAL (STG) Client will respond to multiple choice questions with 80% accuracy.
LPAA SHORT TERM GOAL Client will engage in choosing health care options by indicating preference with care provider 80% of the time.

37. Ability to order at a restaurant Ability to follow directions
Within an out-patient setting, a client's goals may be:
Ability to order at a restaurant
Ability to follow directions
Participation in a conversation
Participation in family decisions
Ability to communicate electronically

38. Impairment-based and participation-based goals in an out-patient setting
LONG TERM GOAL Client will follow directions in his environment.
IMPAIRMENT-BASED SHORT TERM GOAL (STG) Client will follow 2-3 step directives with 80% accuracy.
LPAA SHORT TERM GOAL Client will accurately fill weekly pill box, following directions from partner.

39. TREATMENT Research Supporting Need for LPAA
Take a look at who is included in
TREATMENT

40. Third party payment reviewers
Who is likely included in the decision of treatment with impairment-based therapy?
Largely depends on the setting. In acute care, may include an interdisciplinary medical team, such as the physician, nurses, social worker, physical therapist, occupational therapist, recreational therapist, and care manager.
Third party payment reviewers

41. Who is likely included in the decision of treatment with the LPAA model?
Should include anyone who is a vested communication partner. Opportunities may include:
Multidisciplinary team
Person with aphasia
Family/care partner

42. THERAPEUTIC ENVIRONMENT
Research Supporting Need for LPAA
Taking a look at the
THERAPEUTIC
ENVIRONMENT

43. What does the environment look like with impairment-based therapy in acute care?
In acute care, the environment has more to do with “crisis management.” It is a medical environment, designed to be expeditious in the delivery of medical intervention.
However, more facilities are intentionally designing spaces for families and friends to feel supported during medical management.

44. What does the environment look like with impairment-based therapy in subacute care?
In subacute/in-patient rehabilitation units, family training and education, along with patient care, begin to emerge. However, creating an environment for transfer of training to the patient’s “reality” remains problematic.
Likewise, creating a social environment of camaraderie is often negated by isolation. The establishment of support meetings for patients and/or families can be advantageous in creating an environment of mutual support and understanding.

45. What does the environment look like with LPAA?
Treatment needs to transcend environment so it is “aphasia friendly” and supportive.
A key component of therapy is to create appropriate supports for this transference to the actual environment of the client.

46. This includes external environment
Environment Needs to Complement Social Connectedness
The LPAA scope of practice situates the people with aphasia within social contexts (LPAA Project Group, 2000, 2001).
This includes external environment
Social settings either in the home or community
And the internal environment
Social connectedness felt to others

47. Regarding the LPAA model, one may consider the client’s environment by…
Taking an inventory of your client’s environments. Where does your client spend time, how often, with whom?
Having your client identify meaningfulness of these home and social settings.
Having your client identify perceived social connectedness in these environments.

48. What are the barriers to social connectedness in these environments?
Regarding the LPAA model, one may examine the client’s external environment…
What factors influence your client’s comfort level in a these self-identified environments?
What are the barriers to social connectedness in these environments?
What are facilitators to social connectedness in these environments?

49. Does the social environment support the people with aphasia?
Regarding the LPAA model, one may consider identifying factors in the external environment
Does the social environment support the people with aphasia?
Is the noise level controlled?
Are there extraneous noises and activity?
Are communicative partners facing each other?
Are there multiple conversations at once?
Are their physical supports to facilitate conversation, such as paper and pencil?

50. Regarding the LPAA model, one may examine the client’s external environment…
What is the proximity of furniture in the treatment environment? Does it promote social conversation?
What are the barriers to social connectedness in the therapeutic environment?
What are facilitators to social connectedness in the therapeutic environment?

51. THERAPIST Research Supporting Need for LPAA
Taking a look at your role as a
THERAPIST

52. COMMUNICATION PARTNER
The clinician’s role
When primarily working with impairments, the therapist may be more of a
GOAL SETTER
LEADER
EXPERT
When primarily working in the LPAA model, the therapist may be more of a
COMMUNICATION PARTNER
COACH
PROBLEM SOLVER

53. Research Supporting Need for LPAA
QUESTIONS

54. Questions
Can the LPAA philosophy merge with an impairment intervention? If so, how?
Is there a time for impairment-based therapy and a time for the LPAA approach on the continuum of care? Or can these two models complement each other to best serve the client along the continuum of care? If so, how?

55. Questions
Does decreased impairment result in increased satisfaction in life and participation in life’s desired activities?
If you could create an environment which encapsulates both philosophies, what would it be?

56. Questions
Think of yourself in acute care. What would change if you implemented an LPAA approach? What might be barriers and how could you circumvent them? What would the potential benefits be to the person with aphasia, rehabilitation team, facility?
If you wanted to implement the LPAA approach into your present setting, what is one thing you would propose?
How could you determine if your clinical setting acknowledges the LPAA approach?

57. Re-Framing the Environment for the Client
Dream your ideal external treatment space/environment.
Would it be a physical space or an augmented reality?
What is one element you would make sure is present in your environment to promote social connectedness?