BrICC Brain Injury & Concussion Clinic CLINICIAN TRAINING

BrICC Brain Injury & Concussion Clinic CLINICIAN TRAINING
Summer 2016 Communication Disorders & Sciences University of Oregon

Training Overview PART 1 PART 2 Clinic Purpose & Populations
Motivational Interviewing & eGAS Initial Cognitive Consultations Treatment Selection Administering Assessments Writing Effective SOAPs Scoring Assessments Documentation & Timelines Basic Stats & Types of Scores Rounds & Supervision Interpreting Assessment Data Orientation to Resources Questions?

Learning Objectives By the end of today’s training, you should be able to…. Describe purpose of BrICC and characteristics of client populations. Describe components of an initial cognitive consultation and how to prepare. Differentiate among types of scores, explain what a standard deviation means, and know how to derive a Z score. Consider data from multiple sources to inform treatment selection. Express the purpose of motivational interviewing and demonstrate a working knowledge of how to set up goal attainment scaling using eGAS. Distinguish between restorative and compensatory treatment approaches. Express several considerations and questions relevant to treatment selection and offer an example of a clinical rationale for selecting a given treatment for a client. Access relevant resources to support your work and prepare for weekly rounds.

Part 1

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

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

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

Be Aware of Implications of Attribution
"[I]t is important to recognize and appreciate the multifactorial nature of symptoms in [those seeking] treatment. Cognitive difficulties .....[can be] due to a variety of contributory factors including mTBI, chronic pain, headaches, PTSD, depression, anxiety, sleep difficulties, substance use disorders, and life stressors. While it is normal for both [clients] and clinicians to want to attribute cognitive symptoms to one cause or etiology (e.g., attributing aphasia or neglect to a stroke), such misattributions can actually be harmful or lead to the persistence of symptoms in many individuals. By recognizing the complexity of the originating condition, the clinician creates a more nuanced context for working through the difficulties [with which clients present] and facilitates the recovery process.” --Clinician's Guide to Cognitive Rehabilitation in mTBI, 2016, p. 2 (emphasis added)

Initial Cognitive Consultation

Consultation Schedule
Clinical interview (45 min) Learn about presenting concerns, impact of sx on routine Motivational interviewing + eGAS Present treatment options based on interview data 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

Consultation Preparation: Resources
Procedural information (to be updated soon) InfoCDS → Treatment Areas → Acquired Cognitive Disorders → Cognitive Consultation Process → See document titled ‘BRICC_Consultation Procedures’ Forms Test protocols PCSS and HIT (concussion cases)

Templates – A guide, not a rigid protocol.
RDS > BrICC Clinic > Assessment Templates: Adolescent – 18 & younger, in HS Post-secondary – 18+ in college after HS Adult – 18+ any life context Adapt format, structure and components of templates as needed in consultation with supervisor

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

Basic Stats & Types of Scores

Section Overview Types of scores & relationships among them
Describing and comparing types of scores Interpretation of scores relative to other 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)

Google this now “Psychometric Conversion Chart” Download it Keep it handy Makes a very useful reference!

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 Let’s do a few on the board now

General helpful principles
Draw simple graphics to talk about scores (demo) 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

Assessment Interpretation

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

What does it all mean? Interpretation So much data, so little time!
What hypotheses did you have at the start of the assessment? Go ahead and think of some examples...

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 Selection

Several Treatment Options
ATC/External aid training Direct attention training Metacognitive strategy instruction Goal Management Training Functional skills training Personalized education Environmental modifications/support

Treatment Selection Consider and evaluate from several angles
Assessment data from multiple sources Client data - concerns, characteristics & desired outcomes Values, preferences and priorities of the client Evidence-based practice - refer to the literature Expert knowledge - consult your supervisor

Treatment Selection Ask yourself
What is my rationale for selecting this approach for this client? What do I know about this client’s presenting concerns, assessment profile, and desired outcomes and other characteristics (e.g., awareness, expressed interest in tx, social/emotional needs, support system)? What barriers exist to implementing this approach? What other approaches might be viable? Why? What approaches are not suitable? Why?

Treatment Selection Modify or adjust the approach when necessary
Collect session data What will you measure to determine progress toward goals? How will you take session data? How will you measure progress toward the desired outcome? Is the approach working? Are there barriers to progress?

Questions?

Part 2

Motivational Interviewing
Today I will be talking about Motivational Interviewing, Goal Attainment Scaling and the eGas app. I based some of this presentation on the slides created by Priya for the BRICC clinic orientation last quarter, but I updated and reorganized it for this quarter. Ask a student to define motivational interviewing based on learning about it in McKay’s class last quarter Ask if any students have had experience in MI, and to briefly describe their experience

Motivational Interviewing
Combines interviewing and counseling techniques Grounded in principles of collaboration and client autonomy Elicits “change talk” in client and increases readiness to change Benefits: Increases motivation, client buy-in, and rapport Facilitates selection of goals that have larger impact for the client Why might motivational interviewing be especially important for BRICC clients? It can be difficult for patients with brain injury to generate goals that are related to particular cognitive impairments, and the interviewing techniques can facilitate goal formulation

Principles of Motivational Interviewing
Remember OARS: Open-ended questions Affirmations Reflections Summary Review notes from Cog Rehab class to see examples of each

How do you use it? You should always strive to incorporate motivational interviewing techniques into your initial interview. The app we will talk about today (eGAS) provides some helpful scripts for motivational interviewing, but you can still do motivational interviewing without any technology. Have the clients rate how important each goal is to them on a scale of 1-10, and their confidence in achieving each goal.

What is your role? When reviewing the chart and planning the first session, identify Areas to gather information about Possible motivational interview questions Often the supervisor will take the lead in the initial motivational interview with the client. Talk with your supervisor in advance to clarify what your role will be. Learn from your supervisor, and participate in the interview by practicing reflecting, summarizing, and asking follow-up questions as appropriate. You will also likely continue to use motivational interviewing techniques throughout the term as the clients continue to discuss their goals and progress.

Pairwork Activity: Motivational Interviewing
Think of a personal goal you don’t mind sharing. Could be a new year’s resolution, or something new you have been thinking of trying lately. Write it down. Find a partner Practice motivational interviewing with your partner using your selected goal (see handout). Try to elicit “change talk” in your partner. Later we will use one of your goals to write a sample GAS!

GAS -ask a student to define Goal Attainment Scaling
-ask for a show of hands how many students have made a GAS for a client before

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 Uses a 5-point scale, ranging from most favorable to least favorable outcome Reliably measure goal attainment, T-score, and mean-difference score

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

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 the client in identifying personally relevant goals and define an objective scale to measure outcomes The eGAS may be completed during cognitive consult OR during the first session(s) iPads with eGAS are available for checkout in the GTF office

Why use eGAS? Fills the need for patient-centered outcome measure
First app that combines motivational interviewing 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

Registering a client

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

eGAS: Starting the interview - Role of MI Prompts
Clinician: Hi Jill, Welcome to the UO clinic. So we chatted a little over the phone, 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 forgotten 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 … .

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

E eGAS – Inputting Responses
Problem Identification 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

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]

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]

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

eGAS – what is your role? Before the session During the session
Register the client in eGAS Be familiar with the green buttons on the right side of the screen Practice using the app to enter information During the session Use the dropdown menus and record information in the relevant categories Create the GAS – goal is to complete in first 1-2 sessions After the session Integrate the information gathered into your assessment report or ITP Include the GAS in your SOAP, initial and final ITP

Creating a New goal

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

Questions?

Treatment

Treatment Options Restorative and compensatory approaches
Direct attention training 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 Determine treatment direction
Individual or group delivery options Consultation available with Center on Healthy Relationships (formerly CFT)

6 Guiding Principles for the Treatment Process
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)

Interdisciplinary Collaboration

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

Documentation

Writing Effective SOAPs for BrICC
Heidi Iwashita, M.S., CCC-SLP Updated for Summer 2016

Overview Subjective Objective Analysis Plan

You have learned those terms, but…
What do supervisors expect me to put in each section? Why is it organized this way? Why do I keep getting my SOAPs back with lots of edits? How much is too much information? Too little? What is the rationale for including the information we do include?

Why do SOAPs? The SOAP provides a concise record of services provided on that day Although the format may vary, as practicing SLPs you will have to document that you used therapy time appropriately “Appropriately” means that time was spent working on goals that are individualized for the client and lead to functional cognitive/communicative outcomes

What makes a good SOAP This presentation will provide some guidance and tips for each section As supervisors, our feedback is meant to teach you to write accurate, informative SOAPs similar to the ones that will be required if you work in an adult rehabilitation/medical setting A good SOAP should be: Truthful Complete Unambiguous These tips are not exhaustive. If you have another tip that you think might help future students, please share it!

S: Section

SOAP Notes – S: section – General Tips
Who else is there? Who said what? Attributing statements correctly “Reported” “Noted” “Stated” “The client seemed in a good mood” vs. “the client was in a good mood.” Generally keep the S: section short. However, if there were complicated or serious issues, document that you followed up correctly.

SOAP Notes – S: section – General Tips
Most importantly, in the S: section, CAP Clarify any ambiguities Attribute statements correctly Put our minds at ease – don’t make us worry unnecessarily about the client! If there was cause for concern, how did you address that?

SOAP Note examples – S: Section
When there is something out of the ordinary reported by the client S: TTT and his mother, Mrs. T, arrived ten minutes late to his scheduled appointment. His mother reported that TTT experienced significant pain in his foot over the break, but is now doing “much better.” S: OOO reported that she was diagnosed with type II diabetes during the past week, and it has been “very stressful” for her.

When there is nothing out of the ordinary, what would that look like?

S: RRR arrived to today’s session on time with her husband Mr. R, who stayed in the lobby. RRR seemed to be in good spirits and readily engaged in conversation with the clinician and the clinical supervisor for the entire session.

What concerns do you have reading this S: section? S: QQQ reported that, since her stroke, she always feels “stuffed up to [her] neck.” She, therefore, does not eat during the day. QQQ expressed desire to meet with a neurologist. QQQ and her partner, Mr. Q, talked about her Obsessive- Compulsive Disorder (OCD). Mr. Q joined QQQ in the session.

S: QQQ reported that, since her stroke, she always feels “stuffed up to [her] neck.” She, therefore, does not eat during the day but does not report having difficulties with swallowing. In response to follow-up questions by the clinician, she clarified that she has not lost weight, that she eats at night, and that she takes a multivitamin. QQQ expressed desire to meet with a neurologist, and the clinician told her she would look into a referral. QQQ and her partner, Mr. Q, also reported that she displays symptoms of Obsessive-Compulsive Disorder (OCD), but she has not been formally diagnosed with the disorder. Mr. Q joined QQQ in the session.

O: Section

With Tables Tables are nice if you have quantitative data
It’s good to include previous scores for comparison when you can Dates should go across the top, not down to the side, with the most recent date on the right If you use codes like “M” “C”, “+”, etc., be sure to include a key at the bottom of the table designating what these mean

Without Tables Sometimes your data is more qualitative in nature and does not fit easily into tables, e.g. information gained from motivational interviewing If you have a lot of different areas to cover in sentence form, consider breaking it up into subsections with headers in bold Summarize concisely and objectively Focus on information relevant to setting goals (when assessing) and achieving goals that have been set

A: Section

SOAP Notes – A: Section – Philosophy
“The SOAPs are like chapters of a book and each term is a volume of the book, telling the story of that person.” – Alex Ledbetter “The ‘why’ of the O” – Susan Boettcher While the self-reflection is about what you could do differently as a clinician next time, the A section is about what the client needs to do better next time. Do they need more support, different types of tasks, more motivation? Some of the same areas of difficulty that came up in your self-reflection may come up in your A section, but this time you are framing it with a focus on the client rather than on you.

What to Include in the A: Section
Client response to the intervention Reasons/explanations for the client’s performance What to change (if applicable) based on the client’s performance today

CREW Client response Reasons/ Explanations What to change

SOAP Notes – A: Section – General Tips
Don’t repeat information already in your O: section Make sure it follows logically from your data and what you observed in the session; it should not be speculation coming out of nowhere. It should progress logically from the O: section and into your P: section. So if you identified some ways to adjust your treatment based on the client’s performance today, you would explain that in the A: section, and include your steps for following up on that in your P: section. It should include the client’s response to your intervention. Insurance providers are now looking for that as evidence that therapists are actually providing a skilled service by customizing therapy tasks to the individual.

Let’s look at some examples.
In each example, identify: Client response Reasons/explanations What to change (if applicable).

A: Compared to the previous session, YYY required less intensive cueing to place his fingers on the home row keys. However, he experienced more difficulty with limiting the keys pressed to the target keys. This may have been a result of the change in computer or associated with his reduced fine motor control, reported by his mother, since the SMART attack. Similarly, the accuracy that YYY achieved on the AIM drill may have been affected by the change in computer or difficulty with fine motor control. It will be useful to assess YYY’s performance on these tasks using the normal computer during the next session. It may also be useful to have YYY try to use an external mouse (rather than the buttons on a laptop mousepad) to complete the AIM drills. YYY’s lack of strategy use during the AIM drill suggests that more time should be spent evaluating the strategy that is best-suited for him, and giving him concrete examples.

Red- client response Blue – reasons for client’s performance Green – how to adjust tasks
A: Compared to the previous session, YYY required less intensive cueing to place his fingers on the home row keys. However, he experienced more difficulty with limiting the keys pressed to the target keys. This may have been a result of the change in computer or associated with his reduced fine motor control, reported by his mother, since the SMART attack. Similarly, the accuracy that YYY achieved on the AIM drill may have been affected by the change in computer or difficulty with fine motor control. It will be useful to assess YYY’s performance on these tasks using the normal computer during the next session. It may also be useful to have YYY try to use an external mouse (rather than the buttons on a laptop mousepad) to complete the AIM drills. YYY’s lack of strategy use during the AIM drill suggests that more time should be spent evaluating the strategy that is best-suited for him, and giving him concrete examples.

A: Though LLL could not initially recall the order and Step One of the strategy introduced during the previous session, she seemed to benefit from the use of visual supports (a form that could be filled in, and steps written on a white board) and the clinician’s verbal prompts. Throughout the session, LLL’s functional understanding of the strategy seemed to increase from having the opportunity to restate descriptions of each of the steps in her own words. By the end of the session, LLL was able to apply all three steps of the strategy to hypothetical situations through the use of diminishing cues and mass practice. While LLL had difficulty independently determining in which situations she could use the strategy outside the clinic, she responded well to the clinician’s direct instruction and agreed to use the strategy when riding in the car to and from the clinic this week.

Red- client response Blue – reasons for client’s performance Green – plan for the future
A: Though LLL could not initially recall the order and Step One of the strategy introduced during the previous session, she seemed to benefit from the use of visual supports (a form that could be filled in, and steps written on a white board) and the clinician’s verbal prompts. Throughout the session, LLL’s functional understanding of the strategy seemed to increase from having the opportunity to restate descriptions of each of the steps in her own words. By the end of the session, LLL was able to apply all three steps of the strategy to hypothetical situations through the use of diminishing cues and mass practice. While LLL had difficulty independently determining in which situations she could use the strategy outside the clinic, she responded well to the clinician’s direct instruction and agreed to use the strategy when riding in the car to and from the clinic this week.

A: Based on a rating of at least 4 on PPP’s homework assignments, it was to be concluded that she can accurately follow complex instructions, write concisely, and alternate attention in a functional setting. However, because she was unclear about the “Writing Concisely” rating scale, more data should be obtained. Based on the results of the BRIEF-A, PPP does not demonstrate clinically significant deficits in executive functioning. Considering her performance on assessments, on therapy tasks in the clinic, and on homework tasks, PPP may not benefit from further speech and language services, and dismissal should be considered.

A: SSS continued to demonstrate increased self-efficacy during today’s session. She effectively restated the strategies in her own words and used analogies to describe them (e.g. “The steps are like my self-itinerary.”) Statements like these, as well as her increased use of the strategy tracking chart throughout the week, represent SSS’s increased understanding and ability to generalize the strategy to functional situations. SSS also identified that “breathing” (step 2) and “choosing a focus” (step 3) are “controllers” that she can “apply to triggers” when feeling overwhelmed. While SSS had a high level of independent success when applying her strategy to clinician-generated situations, she had greater difficulty remembering to implement them while using APT-3 as a generalization task. This may be attributed to her previous experience with APT-3, in which she was focused on completing the task to the best of her ability, and not on the explicit use of metacognitive strategies. SSS endorsed the clinician’s recommendation of practicing her strategy outside of the clinic room in the upcoming sessions, stating that although it “scares” her, it would be “worth trying.”

A: MMM’s successful performance during each step of the visual schedule indicates that he is capable of using an aid of this type. It will be helpful for the clinician to select one keyword (e.g. “finished”) to use as a verbal prompt during subsequent training of the visual schedule. MMM’s performance on the memory book activity suggests that it may be beneficial to focus on how to use the book, rather than focusing on his knowledge of the book itself (e.g. name, purpose). Altering the steps to include more functional ways to use the book during conversations (e.g. how to comment and ask questions about the topics) will be necessary for MMM to use the book during everyday life.

P: Section

P: Section Can be in the form of a numbered list
List items should naturally follow from issues raised in the S: or A: sections Any modifications to current approach? New approaches to consider? Follow ups? “Continue [current approach]” if it is working

Main Ideas S: section – CAP Clarify any ambiguities
Attribute statements correctly Put our minds at ease In the A: section, include CREW Client response Reasons/explanations What to change

Documentation & Timelines
Initial Consultation Reports Arrange due date with supervisor SOAPs 24-hour turnaround Self-Reflection 36-hour turnaround ITP/Progress Summary

Rounds & Supervision

Rounds Group supervision Clinical problem solving
Every week TU 4:00-5:00pm Oral case presentation + questions (Case presentation scripts forthcoming) Expectation = concise, complete oral reporting per template, with increased fluency as the term progresses

Clinical Supervision Meet for individual supervision as needed
Arrange by Amount and frequency vary Fades as skills grow – supervisor gradually takes on role of consultant

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

Next Steps Complete follow-up readings Review client files
Formulate clinical questions Consider treatment options carefully Determine a plan of action Prepare initial oral case report Present your plan to supervisor

References (2016). Clinician’s Guide to Cognitive Rehabilitation in mTBI: Application in Military Service Members and Veterans Sohlberg, M. M. & Ledbetter, A. K. (2016). Management of Persistent Cognitive Symptoms After Sport-Related Concussion. American Journal of Speech-Language Pathology.

BrICC Brain Injury & Concussion Clinic CLINICIAN TRAINING

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