1. Brain Injury & Concussion Clinic (BrICC)
Supervisors: Heidi Iwashita, Alex Ledbetter, Priya Kucheria

2. Learning objectives Purpose of BrICC Assessment Intervention Paperwork
Inter-disciplinary collaboration
Paperwork
Supervision setup

3. Purpose of BrICC Purpose :
Evaluate clients with acquired brain injuries that are referred to the clinic (most often by physicians)
Identify the nature of persistent cognitive impairment and its impact on functional activities and participation
Provide cognitive rehabilitation and/or counseling services to such individuals experiencing some loss of functional ability or changes from pre-morbid levels impacting daily functioning
Purpose of services is to facilitate client’s return to desired activity or accomplish desired goal in desired context / setting.

4. Purpose of BrICC
Population: This term, BrICC will mostly be adolescents with mTBI. We will try to group clients in BrICC. We have older clients and mor severe clients and will look to add on another BrICC if the numbers warrant.
Impairments and functional deficits
Commonly observed cognitive impairments: attention, memory, executive function
Functional deficits: Impact on ability to attend school and manage academic demands
Somatic concerns: Headache, sensitivity to light, dizziness
Psychosocial changes: Changes in social networks (Friends), irritability, flat affect

5. Purpose of BrICC
Case management: Interdisciplinary collaboration to provide a holistic rehabilitation experience
Service delivery: Group and individual sessions to facilitate peer support and focus services on client’s area of need.

6. Purpose of BrICC EBP Sohlberg & Ledbetter, 2015 mTBI literature
eGAS Training handout
‘Working with families’

7. Assessment
Delivery format
Tests
eGAS
Clinician role

8. Consultation Process Time allotted : 2 hours Components of assessment:
45 mins: Interview
1 hr 15 mins: Standardized tests
Standardized assessments
RBANS
TEA/TEA-ch—as needed and determined by interview
BRIEF—as needed and determined by interview
D-KEFS (selected subtests)—as needed and determined by interview

9. Consultation Process Logistical scheduling
At end of consult, have client fill out scheduling form (NOTE age and assign yellow/green accordingly)
Let your supervisor and Priya know
If new client assign him to the 4pm slot. If that slot is full (4 clinic (individual) rooms are occupied by a client) THEN look at other slots
Once you have confirmed your client’s session, please inform Priya and she will give you the OK to inform Lindsay

10. Consultation Paperwork
Report templates
InfoCDS & RDS
Test protocols
PCSS and HIT (if appropriate)

11. Consult Process
See handout titled Cognitive Rehabilitation Consultation Procedures located on: InfoCDS  Treatment Areas  Acquired Cognitive Disorders  Cognitive Consultation Process  See document titled ‘BRICC_Consultation Procedures’

12. Standardized Batteries
RBANS:
Video training webinar:
Refer to the presentation titled ‘RBANS Update: Repeatable Battery for the Assessment of Neuropsychological Status’ by Anne-Marie Kimbell, PhD
TEA / TEA-ch:
McKay Moore Sohlberg, PhD class
BRIEF:
Powerpoint training:
D-KEFS:
Video training webinar:
Refer to training by Gloria Maccow, PhD

13. Outcome Measure: eGAS
eGAS : An app developed by Dr. Sohlberg and team to identify functional goals and develop an individualized outcome measure. In other words, the app allows a clinician to assist client in identifying personally relevant goals and define an objective scale to measure outcomes
Motivational interviewing: A collaborative, counseling/interviewing technique used to enhance client’s metacognitive awareness and promote client autonomy in identifying functional goas.
GAS: A set of procedures that helps create individualized outcome measure in the form of a 5-point scale (levels ranging from most favorable to least favorable outcome)

14. Outcome Measure: eGAS
The eGAS may be completed during cognitive consult OR during the first session

15. Initial interview Your role
Before session - Be sure you are well acquainted with the green buttons on the right hand side of the screen. Make sure you’ve registered the client in Egas (will see shortly)
During the session - Be comfortable with the dropdown menus and recording information into the relevant categories
After the 2nd session (when GAS has been generated) – integrate the information gathered into the eval templates

16. Why use eGAS? Fills the need for patient-centered outcome measure
First app that combines motivational interviewing skills with goal attainment scaling procedure to make it easy for the clinicians and clients to collaborate and identify personally relevant goals and outcomes
Flexible design of the app – allows clinician to adapt the interview and data taking process to cater to individual client needs

17. Grounded in principles of collaboration and client autonomy
Components: MI + GAS
MI:
combines interviewing and counseling techniques to elicit client motivation and facilitate identification of functional goals.
Grounded in principles of collaboration and client autonomy

18. We are going to see an example GAS soon
Components: MI + GAS
GAS:
measurement methodology that allows clinicians to develop and monitor progress on individualized goals
This criterion-referenced measure serves as an outcome tool for measuring longitudinal change in an individual
We are going to see an example GAS soon

19. Begin by selecting the eGAS app on your iPad’s home screen
Time to dive into how a clinician would use eGAS during session and what that would look like.

20. Sample case: Jill
- Click on the dropdown menu under the ‘Select a Client’ option and select ‘Jill’

21. eGAS: Starting the interview - Role of MI Prompts
Clinician: Hi Jill, Welcome to the UO clinic? So we chatted a little over the phone/ I read your medical report, and you noticed some changes since the TBI…How did you know you were having a problem?
Jill: Well my grand son noticed I had forgotton how to access my texts ; because I wasn’t responding to any of the texts that he was sending them. I would usually call in response to the text. I also noticed my speech has begun to decline since my PPA diagnosis. Post TBI; I’ve noticed more changes [Clinician taking notes on scratchpad] – I also wanted to learn how to .

22. eGAS: Inputting responses
Scratchpad function serves as a notepad for taking notes. Allows clinician to document details pertinent to the eGAS process and attend to the client without interruption during the interview process.
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

23. eGAS: Role of GAS categories - Inputting responses
Problem-Id phase*
Functional goal domains – Common activities and settings that a client wishes to be successful in/execute independently.
What do you think this would be in Jill’s case?
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

24. eGAS : Activity and Context
Buy-in phase*
Activity – specific task that the client wishes to accomplish
Context – variables and components that impact facilitate or deter accomplishment of task; issues that clinician should be aware of that may impact selection and execution of intervention
Clinician: So it sounds like you want to start working on your ability to text…
Jill: Yes, I would like to be able to send, and reply to texts
[Activity]
Clinician: Well, what would you need to accomplish this?
Jill : laughs and says – lots of patience. Also – I need to be familiar with using my smartphone and typing on a small screen –- maybe my grandkids could help me. Once I start to text, I could keep in touch with them [Context]

25. eGAS: Therapy Approaches; Underlying Cognitive domain
*Strategy selection phase
Cog domains – areas of impairment. Might get some of this info from interview + testing
Therapy approaches – intervention approaches
Clinician: Wow, its great that you have identified a goal that you would like to work toward. [affirmation] You stated wanting to learn how to send and receive texts…what would be the first thing you would like to work on?
Jill : probably learning how to send a text
Clinician: How difficult do you think that would be?
Jill : Very – cause I don’t have the best memory [Cog domain]
Clinician: You stated that you were working on learning to text before your injury – what have you tried….?
Jill : I just had to keep practicing everyday so I don’t forget what I learned. I could only remember a few steps at a time..after my TBI…I feel like my ability to pay attention and remember lots of things has reduced [Cog Domain and intervention approaches]
Clinician: Based on what you’ve told me…XXX..may I share a strategy …?
Jill : Sure ! [Therapy Approach]

26. Sample Goal Attainment Scale
Let’s look at Jill’s scale!
Five levels ranging from -2 to +2
Baseline is at -1

27. Key characteristics of a scale
Let’s look at the GAS checklist and evaluate whether Jill’s scale meets these criteria
Each level is Objective, Measurable, Quantifiable – I can observe and measure the behavior;
Roughly equidistant levels – Are units of measurement non-overlapping; are they progressing in a logical fashion
Discrete/Unidimensional – are you measuring singular aspects of a functional goal? Is there just one variable that you are measuring?
Meaningful – Did you use the MI techniques correctly
Functional domain directly related to the type of therapy approach and / or cognitive domain
Unit of measurement will also tie into the intervention approach

28. Steps for creating a GAS
Define levels
Check whether scale meets ALL GAS criteria*
Can be modified later
Weight the goal
Define measurement

29. Creating a New goal

30. Registering a client

31. Last step: Printing the final summary report
Lesson descriptions should be brief.

32. BrICC: Intervention
Referrals : through BRICC assessments. Clients will be gradually added
Service delivery:
Group and individual
Group session: 3:30 – 4:00; Individual: 4:00 – 5:00*
First session: Only group session; no individual session
Interdiscliplinary collaboration
Collaborating with Counseling Couples & Family Therapy (CFT) to provide a holistic approach. Attend not just to the cognitive but also the emotional, psychological, and social aspects of recovery

33. Collaboration with CFT
Student Clinician assigned to accompany SLPs to group sessions
Attend to the psychosocial and emotional aspects of functioning that has been impacted by brain injury
Sit in on group sessions and interact with clients. She will also be present for the group supervision meetings.
Attend individual sessions per client needs / clinician requests
Students conducting assessment or intervention may report their observations to CFT clinician after discussing the case / client with their respective supervisors.

34. Intervention Therapy approaches - restorative to compensatory
Direct attention training
Functional skills training
Metacognitive strategy instruction
External aid training
Personalized education
Environmental modifications/support

35. Intervention Clinician role
First session will be conducted by supervisors / 2nd year clinicians
Starting second week of clinic, clinicians will be responsible for delivering group and individual sessions.
Individual intervention pairings
Excel sheet contains details regarding client-clinician pairings and group clinician assignments
GIVEN THAT WE HAVE OUR FIRST SESSION AS A WHOLE GROUP SO WE’LL HAVE AN IDEA ABOUT CLIENT NEEDS AND INTERVENTION DIRECTION PRIOR TO AN INDIVIDUAL SESSION SO WE’LL KNOW WHO CAN BE MORE INDEPENDENT. WE WILL JUST NEED TO CHECK ON WHETHER SOMEONE IS COMING INTO THE INDIVIDUAL ROOMS AFTER US

36. First Group Session Different Format
90 minute group session
Introductions (name, school, what brought you here)
View Sylvia video —what resonates and does not resonate
Therapist shares samples of types of issues/interventions
If moving forward, try to set functional goal areas and identify approaches
Jobs: agenda, set up room, video, make template for client
Will match students with therapists afterward

37. Other group sessions 30 minute group session Setup
2 lead clinicians – split lesson planning and execution
Remaining clinicians are “passive” data collectors

38. Paperwork Sample paperwork up on RDS/InfoCDS
Agenda for group sessions due Friday at noon
SOAPs part of individual session SOAP notes
Lesson plan for individual session due 24 hours prior
SOAPs due Friday at 8 am
ITP
Midterm: First draft January 22nd
Final draft due March 1

39. Supervision setup Group meeting Individual meeting Communication
From 6pm – 7 pm, Room TBD
Primary supervisors for intervention: Priya, Alex, Heidi
Assessment: Priya, Alex
Individual meeting
On Tuesdays during BRICC slots. your respective supervisor
Communication
Please feel free to discuss strategies or ideas to best serve your learning needs with your supervisors. Help us, help you !

40. Group Meeting Process Be prepared to discuss each week Problem solving
Treatment target (adjustment targets and cognitive issues)
Intervention Approach—Make sure you can explain rationale for selection
Session progress measures related to targets
Outcome measures related to intervention
Problem solving
Teaching opportunities
Know all the clients
Report your hours every week; if you feel like a client is not appropriate for continued services, inform Priya so that a new consult / case may be scheduled for you

41. WEEK DATE TOPIC Week 1 Jan 5
Case presentation re: client; Check files for up to date paperwork; Writing tips / tricks
Week 2
Jan 12
Intervention selection; Case presentation; Writing tips / tricks
Week 3
Jan 19
Group session feedback; Case presentation; Outcomes; Writing tips/tricks; ITP
Week 4
Jan 26
Group session feedback; case presentation and progress toward outcomes; types of interventions and rationale for selection; Carryover/Generalization & Impact of tx
Week 5
Feb 2
Group session feedback; case presentation; writing feedback; New consults discussion; Handout scheduling forms
Week 6
Feb 9
Group session feedback; new consults; scheduling for Spring term
Week 7
Feb 16
Group session feedback; Final outcome;
Week 8
Feb 23
TBD
Week 9
March 1
Final ITP reporting feedback; final meetings setup
Week 10
March 8
Final lessons learned

42. QUESTIONS / COMMENTS / CONCERNS?
THANK YOU!
QUESTIONS / COMMENTS / CONCERNS?