BrICC Brain Injury & Concussion Clinic CLINICIAN TRAINING Winter 2018 Communication Disorders & Sciences University of Oregon

Training Overview PART 1 Short break Pre-Practicum Survey & Knowledge Pre-Test PART 2 Cognitive Domains Welcome & Introductions Assessment Logistics Treatment Processes: Rounds Goalsetting & GAS Processes: Documentation Transitions Q & A Gots & Needs Before this training, make sure the students have: Checked their schedules and let us know if they have any questions or concerns about assignments Confirmed session times with clients Asked clients if they prefer to get reminders before each session

Learning Objectives By the end of today’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.

Part 1

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

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

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)

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?

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

Logistics BrICC Rounds: Every Friday 2:00-4:00 – may incorporate training sessions within this time block First rounds: 1/26/2018 in Room 361 Will include a training session on ITP writing 2/2/2018 to 3/16/2018 in Room 271

Documentation Due Dates Lesson plans due 24 hours before the session starts SOAPs and self-reflections due 24 hours after the session ends Initial draft of Assessment Report due within a week of the consult Initial draft of the ITP due: by 9am MO 1.29 Final ITPs due by 9am MO 3.19

BrICC Rounds ALEX

Rounds Group supervision/clinical problem solving You’ll receive the presentation order the day before via email – 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

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

Skills Developed in Rounds Clinical Decision Making “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

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, including learning record Email it to your supervisor at the end of the term Must complete to pass clinic

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)

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.

Documentation & Resources on InfoCDS ALEX

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 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.

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

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

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

Any questions so far? Short break

Part 2

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

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

Assessment: Initial Cognitive Consults

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

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 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 given score from mean (X – M)/s = Z (scores’s distance from the mean)

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

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?

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)

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

Concussion Treatment

What is a Concussion Also referred to as Mild Traumatic Brain Injury (mTBI) Application of biomechanical force to head or neck resulting in pathophysiological brain functioning Results in somatic, cognitive, and emotional/behavioral symptoms Somatic – dizziness, headache, nausea, fatigue Cognitive – memory dysfunction, lack of attention/concentration, lack of awareness of surroundings E/B – anxiety, depression, irritability LOC and PTA no longer major indicators of mTBI symptoms Symptoms like sleep disturbance or sensitivity to light or sound enter in persistent stage

Concussion Recovery 80-90% of mTBI cases resolve symptoms within acute stage of 7-10 days post-injury 10-20% of mTBI cases develop persistent concussion symptoms (PCS) DSM-IV and ICD-10 provide differing definitions of PCS but general requirement is presence of 3 or more symptoms >3 months post-injury Risk factors to developing PCS – female gender, premorbid psychological symptoms (i.e. depression/anxiety), history of mTBI Cause of PCS is likely a combination of psychogenic and physiogenic factors PCS also referred to as post concussion syndrome Physiogenic factors – alterations in blood flow and glucose metabolism – however, physiological factors mainly resolve

Concussion Management Team (CMT) HEDCO clinic is part of Eugene concussion management team Other team members: Slocum – physician and neuropsychologist (where our referrals come from) Physical therapy Center on Brain Injury Research & Training (CBIRT) – provide school support Behavioral health Injury ➤Slocum ➤ PT/HEDCO/Behavioral Health/support from CBIRT ➤ Independence https://cbirt.org/ https://www.slocumcenter.com/ http://www.cprphysicaltherapy.com/

Our Role Address cognitive symptoms/dysfunction by targeting functional goals developed with clients through Goal Attainment Scaling dependent upon client needs Examples: development of strategies to remember to complete daily tasks Strategies to improve school performance (i.e. completing assignments) Goal of therapy is to return to independence via ability to use cognitive strategies to improve daily lives

15% with prolonged symptoms 5% with prolonged symptoms Acute Phase Persistent 100% of concussion patients 15% with prolonged symptoms Chronic 2% with long-term sequelae NOW 0-8 weeks > 8 weeks > 1 year Early Management Phase Acute Phase Persistent 100% of concussion patients Chronic Our Goal 5% with prolonged symptoms 80% of concussion patients <2% with long-term sequelae Here are two timelines—what happens currently, and what we hope will happen with everyone in this room working together. Currently what we see is a lot of effort expended in what’s considered an acute phase. Understandably, a lot of effort goes into identifying and diagnosing concussion cases, then referring them to various service providers. Because the sx profiles are so variable, and because so many different providers with varied roles interact with the patients in multiple settings, care delivery can become fragmented and inefficient, perhaps less effective. So it seems that the challenge with which we're faced is that of determining together how best to coordinate care to save healthcare dollars and more efficiently serve the complex needs of our patients As we’ve been talking about today, our goal is to reduce the number of youth in our region who move to the persistent stage --- and also to help those that do have persistent sx to move forward. We do this by better identification and adding EBP for early management phase—prevention of persistent symptoms. Essentially, the various providers (PT, neuropsych, behavioral health, etc), tee up the patient for the next provider so there’s not duplication of services, but instead support of and reinforcement for what’s been done. Inevitably, some will move forward to the persistent stage--and that’s what I want to talk with you about for a few minutes—though we do hope through our collaborative efforts to reduce these numbers. These patients are very expensive in terms of healthcare utilization and persistent sx can be devastating to the youth’s lives. Hence, it’s important that we have effective ways to help them improve. 0-10 days 2-8 weeks > 8 weeks > 1 year

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.

Goal Attainment Scaling (GAS) Individualized, objective outcome measure based on client-centered goals 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

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. Check out iPads with eGAS from HEDCO 270

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

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

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.

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 We appreciate your feedback! Please let us know about your further training needs.