1. BrICC Brain Injury & Concussion Clinic CLINICIAN TRAINING
Winter 2019
Communication Disorders & Sciences University of Oregon

2. Before we start the training…
Pre-practicum survey
Knowledge questions

3. Training Overview PART 1 PART 2
Pre-Practicum Survey & Knowledge Pre-Test
Assessment
Treatment
Welcome & Introductions
Goalsetting & GAS
Logistics
Transitions
Processes: Documentation
Gots & Needs
Q & A

4. Learning Objectives
By the end of tomorrow’s training, you should be able to…
Describe the purpose of BrICC and characteristics of client populations.
Locate checklists, templates, and instructions on infoCDS to assist you in preparing for rounds, consults, treatment, and completing required documentation.
Describe how cognitive domains operate in daily life and offer examples of how impairments to cognitive domains interfere with functioning.
Describe components of an initial cognitive consultation and how to prepare.
Explain guiding principles of treatment selection and delivery for cognitive rehabilitation.
Describe the ingredients of selecting the right treatment for a client and offer specific examples of how client variables influence that decision.
Describe and demonstrate how to identify client-centered goals and desired outcomes and how to use goal-attainment scaling.

5. Part 1

6. BrICC 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

7. 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

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

9. Additional complications
Cognitive symptoms may be exacerbated by many factors, which may include
Mental health issues, e.g. anxiety, depression, PTSD
Sleep difficulties
Substance use disorders
Life stressors
Physical pain
How to proceed
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)

10. 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

11. *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*

12. 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

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

14. Logistics: Prior to First Session
Check your schedules
Have scheduled meeting with supervisor: questions/concerns
Confirm session times with clients
Ask clients if/how they prefer to get reminders before each session
Submit initial CHARTR for every client

15. Logistics: BrICC Meetings
Thursdays 11:00 – 1:00 in HEDCO 370
Discussion of cases
Each rounds meeting will include discussion on specified topic
ITP training on 1/17/19
EBP discussion for each client on 1/17/19
Finalized topic list will be sent out next week
Last 2 weeks of meetings: video rounds
Meetings: 1/17/19 – 3/14/19

16. Video Rounds Presentation
More details during BrICC meeting 1/17/19
You will each sign up for a time to present during the last 2 weeks of rounds
Choose a client
Show a video clip of your client implementing your chosen treatment approach for the term

17. Documentation Due Dates
Lesson plans due 24 hours after the previous session concludes
SOAPs and self-reflections due 24 hours after the session concludes
Initial draft of Assessment Report due within a week of the consult
Initial draft of the ITP due: by Midnight Mon. January 21st
Final ITPs due by Friday 3/15 at Midnight

18. BrICC Rounds
ALEX

19. Rounds Group supervision/clinical problem solving
You’ll receive the presentation order the day before via – changes weekly
Oral case presentation + questions
Use the checklist to prepare – focus on including all elements and being clear – conciseness and fluency will come naturally later in the term

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

21. Skills Developed in Rounds
Clinical Decision Making
“Clinical knowing”
Reporting
“Saying what you know”

22. 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

23. 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

24. 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)

25. 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?

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

27. 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?

28. 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…. .

29. 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 .

30. 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…. .

31. 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.

32. Rounds Presentation Example
Show videos from Jim’s computer

33. Documentation & Resources on InfoCDS
ALEX

34. 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

35. 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
We won’t be able to go over all the procedures and expectations in this brief training, so you’re expected to look at the checklists, follow them, and communicate with us if anything is unclear. Go ahead locate those documents and download them to store in a folder where you can easily access them later.

36. Expectations Complete Initial Consultations Plan & Implement Treatment
Prepare for and participate in BrICC Rounds
Complete Rounds Portfolio
Complete SOAPs and ITPs
Complete focused self-reflections
Reflect on supervisor changes to your documents

37. 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

38. Supervision Primarily group supervision (rounds/training sessions)
Individual support through communications
Office hours
Midterm IPPE (performance evaluation) meetings – week 6
Download and refer to individual supervisor guidelines

39. Any questions so far?
Short break

40. Part 2

41. 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

42. 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
Interpret test performance relative to routine function – connect to interview data

43. 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

44. Assessment: Initial Cognitive Consults

45. 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 the Consult Checklist to prep for consults
Use complete sentences, narrative format

46. 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

47. 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

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

49. 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

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

51. Scoring – General Helpful Principles
Know the different types of scores possible
Read the scoring procedures in the manual
Read what the manual says about how to interpret scores
Draw simple graphics to talk about scores

52. 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

53. 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?

54. Treatment

55. 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)

56. 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

57. 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?

58. Measuring Progress You will collect two types of data:
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)

59. Treatment Delivery
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

60. Treatment: Strategy Selection
Evidence-based
Collaborative
Customized to client (e.g., client’s own words)
Task-general or task-specific
To self-regulate state of mind or given task
Will give examples of different types of strategies from the literature and examples of how to customize for client; will discuss how to have client rate utility of strategies selected and how to use that data along with objective session data to further inform strategy selection and session planning.

61. Transitions: End of Term
Involve the next clinician to facilitate a smooth transition
When sharing final progress with your client, take a collaborative approach
ask them what worked
how the strategies worked
Present progress during the last session in a client-centered and client-friendly way, without presenting the formal ITP in the last session—this means we can continue getting final data during the last session

62. Transitions: End of Therapy
Start preparing the client early in the term for possible dismissal if this might be the last term
Connect your client to community resources
Develop a maintenance plan or check-in plan

63. Learning Objectives Checkpoint
Make sure you achieved the learning objectives today!
Describe the purpose of BrICC and characteristics of client populations.
Locate checklists, templates, and instructions on infoCDS to assist you in preparing for rounds, consults, treatment, and completing required documentation.
Describe how cognitive domains operate in daily life and offer examples of how impairments to cognitive domains interfere with functioning.
Describe components of an initial cognitive consultation and how to prepare.
Explain guiding principles of treatment selection and delivery for cognitive rehabilitation.
Describe the ingredients of selecting the right treatment for a client and offer specific examples of how client variables influence that decision.
Describe and demonstrate how to identify client-centered goals and desired outcomes and how to use goal-attainment scaling.

64. For Training Session 2 Friday 10:00 – Noon
Review one client’s diagnosis
Prepare a five-ten minute presentation
Include the following information:
What you’ve learned about the disorder
How the disorder might impact cognitive functioning
How those challenges might impact your client’s daily life
What’s one activity you would potentially implement within a session to functionally address those cognitive deficits

65. 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.