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

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

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 email to clarify any further questions that come up.

Part 1

Welcome & Introductions Two BrICC supervisors during the summer: Alex Ledbetter, PhD, CCC-SLP – will be in touch by email, 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?

Before this training, have you… Checked your schedule provided by Alex in the email 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)

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 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

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

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

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

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)

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)

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

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

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

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)

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

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

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

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

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

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

Standardized Batteries RBANS http://www.pearsonclinical.com/psychology/products/100000726/repeatable-battery-for-the-assessment-of-neuropsychological-status-update-rbans-update.html#tab-training 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 http://www4.parinc.com/Products/Product.aspx?ProductID=BRIEF LASSI http://www.hhpublishing.com/_assessments/lassi/ D-KEFS http://www.pearsonclinical.com/psychology/products/100000618/deliskaplan-executive-function-system-d-kefs.html#tab-training Refer to training by Gloria Maccow, PhD

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

A handy reference Psychometric Conversion Table infoCDS > BrICC > Assessment

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

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

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

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)

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

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 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)

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

*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*

Resources for clients in crisis For non-UO students Crisis Intervention Line – White Bird Clinic (24 hours / 7 days) (541) 687-4000 / 800-422-7558 http://whitebirdclinic.org/crisis Campus resources for students After-Hours Support and Crisis Line – 541-346-3227 UO Counseling Center http://counseling.uoregon.edu https://healthcenter.uoregon.edu/Services/Suicide-Prevention https://oregon-advocate.symplicity.com/care_report/index.php/pid934179?

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

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)

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

Part 2

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

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

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

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 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…. .

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.

Supervision Combination of group supervision (rounds/training sessions) and individual, mostly by email If there are complex client needs or complex personal issues, you may email 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

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

Self-reflections After each session Due within 24 hours Reflect on your own clinical performance Consider our feedback carefully and respond Supervisors may email 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?

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 Email it to your supervisor at the end of the term Must complete to pass clinic

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

“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

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

Registering a client on eGAS

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.

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

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 email to clarify any further questions that come up.

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, 138-149. DOI: 10.1044/2015_AJSLP-14-0128 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.

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?