“Post-TBI Cognitive Treatment:

Acute Inpatient to Outpatient”

Oregon SLHS conference

Kim Frey, PhD, CCC-SLP, CBIS

Director, Speech-Language Pathology

Craig Hospital
 Disclosure

Kim Frey, PhD, CCC-SLP, CBIS

No financial or conflicts of interest to disclose

Kim Frey, Oregon, 10/12/18

 Abstract

Post-TBI rehabilita2on of cogni2ve impairment on the

inpa2ent unit poses challenges, especially with regard to
“func2onal” treatment. Construc2on of treatment
sessions, in both inpa2ent and outpa2ent, benefits from
inten2onal and specific clinical choices. A framework for
treatment construc2on is outlined and integrated with goal
aFainment scaling and intensive aphasia therapy.

Kim Frey, Oregon, 10/12/18

 Arousal – Attention – Language - New Learning Memory – Frontal/Executive Dysfunction

Disordered Confusion / PTA Dysexecutive

Conciousness Delirium [Memory/ [Frontal/ Recovery
[Arousal] [Attention] Learning] Dysexecutive]

Kim Frey, 1/18, Vail, CO & 10/12/18, Salem, OR

 Objectives

•  Describe patient-centered, contextually-

relevant rehabilitation in the inpatient setting.

•  Describe five components of treatment

construction.

•  Provide at least 3 examples of contextually

relevant goals and treatments.

Kim Frey, Oregon, 10/12/18

 Overview

Ideology •  Background and Description

•  H&P
•  Standardized
Assessment • 
• 
Questionnaires
Interview
•  Likert scales

•  Motivational Interviewing
Goal setting •  Goal Attainment Scaling
•  Case studies

Treatment •  Case studies

construction
Kim Frey, Oregon, 10/12/18
 Patient centered care: Ideology

•  Frame of mind for interactions with patients, families,

and team.
•  Care and service delivery focused on meeting the
person's needs, values or preferences

•  Determining, via collaboration, what role patients/

families want to play in care.

•  “…..establishes a partnership to ensure that decisions

respect patients’ wants, needs, and preferences and
that patients have the education and support…”

Na2onal Research Council, 2001, p. 4

In Bamm et al, 2015
Kim Frey, Oregon, 10/12/18 hFps://www.ncbi.nlm.nih.gov/pmc/ar2cles/PMC5342279/
 Patient Centered Care vs Caring for the patient

“I believe that what distinguishes patient-centered care

in its fullest sense from beneficence or better customer
service is that it involves actions undertaken in
collaboration with patients, not just on their behalf.
It requires clinicians to appropriately share power
even when that sharing feels uncomfortable.”
- M. Millenson 2014

Millenson, M, New Roles and Rules for Pa2ent-Centered Care. J Gen Intern
Med, 2014, Jul: 29 (7): 979-980. www.ncbi.nlm.nih.gov/pmc/ar2cles/
Kim Frey, Oregon, 10/12/18 PMC4061351/
 Patient Centered Care: Initiative

Interdisciplinary Programma#c
communica#on outcomes

Pa#ent
&
Partnerships Staff Sa#sfac#on
pa#ents
& Na#onal and Hospital
families Pa#ent & Family
Engagement Ini#a#ve

Kim Frey, Oregon, 10/12/18 Adapted by Frey, K & Johnson, S, ASHA, Denver, CO, 2015
 Patient Centered Care: Patient Engagement

•  Survivor selected real-life goals and validation

•  Motivation and confidence occurs naturally

•  Increased opportunities for practice and reinforcement

•  Generalization is inherent and is likely to be maintained

•  Cultivates team collaboration

•  Neurochemical uptick

Kim Frey, Oregon, 10/12/18

 Patient engagement – Clinically

A willingness to:

Kim Frey, Oregon, 10/12/18

 Patient Centered Care: Review

•  Patient centered care

•  Ideology
•  Programmatically – why makes sense
•  Patient centered care vs caring for patient
•  Value of getting patients engaged
•  5 specific components of patient centered care –
common ground
•  Goal of patient engagement

Kim Frey, Oregon, 10/12/18

Rehabilitation approaches

Kim Frey, Oregon, 10/12/18

 Cognitive Rehabilitation

Kim Frey, Oregon, 10/12/18

Koehler, R et al editors, Cogni2ve Rehabilita2on Therapy for Trauma2c Brain Injury: Evalua2ng the Evidence. Ins2tute of
Medicine of the Na2onal Academies, 2011
Rehabilitation approaches

Kim Frey, Oregon, 10/12/18

Rehabilitation approaches

Kim Frey, Oregon, 10/12/18

 Rehabilitation Approaches: Evidence

Journal of Medical Speech-Language Pathology

Volume 10, Number 2, ix-xiii Newman, J & Frey, K 2015, Kim Frey, Oregon, 10/12/18
 Cicerone et al 2011,
Brain Injury Interdisciplinary Special
Interest Group of ACRM
Attention Practice standard – Direct attention
training - postacute population. Not
recommended for acute population.
Functional Communication Practice standard – pragmatic
conversational skills
Memory Practice standard – for mild memory
impairment – use of internal strategy
training (visual imagery) and compensatory
strategies (notebooks, diary)
Practice guideline – external aides for
memory compensation to improve day-to-
day functioning
Executive Functioning, Practice standard – metacogitive strategy
training (self-monitoring and self-
Problem-Solving, and regulation) as a component of interventions
Awareness for attention, neglect, and memory
Practice guideline – training formal
problem-solving strategies (“goal-
management training”) in everyday
situationsKim
in post-acute TBI. 10/12/18
Frey, Oregon,
Cappa, S.F., et al., 2005
Task Force on Cognitive Rehabilitation -
European Federation of Neurological
Societes
Grade A (Definite) recommendation for
postacute population.
Insufficient evidence for communication
training in TBI
Grade C (Possible) - memory strategies
without electronic aid
Grade B (Probable) - specific learning
strategies like errorless learning
Grade C (Possible) - non-electronic
external memory aides i.e., diary or
notebook
Grade B (Probable) - electronic external
memory devices i.e., computers, paging
systems or portable voice organizers
Grade C (Possible) - virtual environments
Not investigated
18
 Rehabilitation approaches
Restorative/Traditional Compensatory/Contextual

Treatment outcomes
Generalization
Active ingredients
Quasi-contextual Direct instruction

Kim Frey, Oregon, 10/12/18

Kim Frey, Oregon, 10/12/18
Kim Frey, Oregon, 10/12/18
 Back to patient engagement
Patient engagement matters and can
drive emotions, attention, motivation and
thus learning or changing behaviors

Avoid:
•  Repetitive, mindless tasks where patient is going through
the motions
•  Jumping from one task to the next
•  Doing general cognitive rehab with the assumption that
working on general underlying cognitive functions will
affect change in one or any behaviors/abilities

Do:
•  Do task analysis to determine discrete skills need to
practice and provide explicit and systematic practice
Specificity (specificity, repetition)
Repetition •  Identify specific, motivating, salient tasks the patient
Intensity needs to improve on (specificity, salience)
Salience •  Provide many opportunities for practice (repetition,
Kim Frey, intensity)
Oregon, •  Use strengths to compensate for challenges (salience)
10/12/18
 Definitions

Ø  “Functional treatment”
1.  Patient centered
2.  Contextually relevant
3.  Goal directed
Functional therapy

Patient-centered care Patient-centered care

Functional therapy Contextually - relevant care

Kim Frey, Oregon, 10/12/18

Specific goal directed
 4) Approach: Patient Centered/
Contextually Relevant (PCCR)

Restorative
Compensatory

Patient Centered/Contextually Relevant

Quasi-contextual Direct / Compensatory training

Kim Frey, Oregon, 10/12/18

 Patient Centered & Contextually Relevant
Framework
Explicit and Systematic
training
Strengths & Cognitive
Compensatory and
supportive strategies
Therapist collaborates with
patient /family to determine
salient tasks, goals, and
supportive strategies.
Tasks and goals are specific/
relevant to the current
context with targeted practice
and supportive efforts in
those contexts
Kim Frey, Oregon, 10/12/18
• Task break-down / analysis into small, components that can be addressed and
achieved
• Identification of specific process to target
• Systematic, explicit, consistent instruction and practice
• Multiple opportunities for practice
• Focus on patient strengths
• Compensatory strategies
• Family and team training for positive supports and enviornmental modification
• Visual supports and frequent and cumulative review
• External aids – smartphones, tablets, smartpen, apps,wipe off boards, visual supports
• Consistently high rates of success
• Teaching generalizable strategies and planned, programmed generalization
• Modifications to environment
• “Begin with the end” to determine goals
• Discussion with patient/family to understand patient’s values, experiences, interests,
and goals.
• Identify ways there can be collaboration in targeted goals, communication across
therapies, caregivers, and family, and multiple opportunities for practice
• Systematic modeling of component skills
• Training for supportive strategies in relevant contexts
• Not only are tasks practiced in relevant contexts, but goals are set relative to current
context
• Personally relevant goals
• Individualized skill training in natural environment
• Cues/coaching/modeling to achieve success
• Teaching to mastery
• Inpatient – Targeting safety and independence on the unit
Ylvisaker, 2002
Approach: Restorative / PCCR

Kim Frey, Oregon, 10/12/18

 MAAT / ABT + placebo / methylphenidate
4, every other week, 50 min sessions, with phone calls in between weeks

Kim Frey, Oregon, 10/12/18

 MAAT / ABT + placebo or methylphenidate
4, every other week, 50 min sessions, with phone calls in between weeks

Kim Frey, Oregon, 10/12/18

 PCCR Approach: Inpatient

Interdisciplinary
•  Goals identified by patient’s needs – begin with end
•  Goals relevant to the context
•  Goals addressed collaboratively by each discipline

End goal Short-term goals Task

Where do we need to get? What do we need to do to get patient there? How support pa#ent to success?

Patient discharge from hospital Transfers because wife cannot assist; Organize & write-out steps to
Dressing; help learn so can practice w/
Demonstrate safety by not getting up on own Physical & Occupational
therapy

Kim Frey, Oregon, 10/12/18

 Implementation: Inpatient PCCR
Step 1: Assessment / Outcome
Ø  Identification of needs in current context

Ø  Identification of real-life goals Assessment
Ø  Identification of team support strategies End goal
Ø  Interview, informal observations, standardized assessment
Ø  Medical, social, vocational, psychosocial history
Ø  Identification of individual’s interests and preserved strengths
Ø  Identification of self-monitoring and outcome tools and measures

Step 2: Collaborate to Set Individualized Goals

Ø  Goals are selected by the survivor
Patient and
Ø  Individual and therapist collaborate to identify achievable specific goals clinician set goals
Ø  Therapist guides toward defining steps and tasks to achieve goal together
Ø  Goals are shared by the entire team if possible
Step 3: Treatment
Ø  Treatment targets strategies to bridge gap between what survivor
struggles to do independently and what survivor can successfully do with support
Ø  Treatment tasks are relevant to and occur in survivor’s current context
Ø  Treatment tasks are specific to survivor’s end goals
Ø  Treatment tasks are designed so that opportunities for repetition occur throughout the day Practice
Ø  Survivor and therapist collaborate toward end goals real-life task
Ø  Compensatory strategies, modifications of environment, individualized instructional approaches

Newman, J & Frey, K 2015 Kim Frey, Oregon, 10/12/18

 Step 1: Assessment

Ø  Review of medical, social, voca2onal, psychosocial history

Ø  Interview, informal observa2ons, standardized assessment

Ø  Iden2fica2on of individual’s
Ø  cogni2ve-communica2ve impairments
WHAT
Ø  interests and preserved strengths
Ø  poten2al support strategies
HOW

Ø  Needs/goals in current context with pa2ent/family/team

Johnson, S & Frey, K, ASHA, Denver, CO, 2015 Kim Frey, Oregon, 10/12/18
 Step 2: Setting goals

Discharge
from the hospital

Long term goal

Short term goal

Improve safety & independence
by _____________
Safety & Independence (Goal AHainment Scaling)

for discharge

Johnson, S & Frey, K, ASHA, Denver, CO, 2015 Kim Frey, Oregon, 10/12/18
 Step 2: Setting Goals

1.  Goals are selected by the individual in collabora#on

with clinician

2.  Individual and therapist collaborate to iden2fy realis#c

and achievable goals

3.  Therapist guides toward defining steps to achieve goal

4.  Goals are shared by the en#re team

Newman, J & Frey, K 2015 Kim Frey, Oregon, 10/12/18

 Goal Attainment Scaling
Goal 1 Goal 2
Level of
A*ainment
Goal AFainment Scaling
Much more
than expected
+ 2

Somewhat
more than
Mo2va2onal Interviewing expected
+ 1
Expected level
of outcome
0
Somewhat
less than
expected
- 1
(Baseline)
Much less
than expected
- 2

Kim Frey, Oregon, 10/12/18

 Step 2: Set Goals –
Goal Attainment Scaling (GAS) – What is it?

•  Structured conversa2on that puts goals and achievement

in pa2ent terms

•  A standardized mixed-method (quan2ta2ve and

qualita2ve) approach to assessing, scoring, and measuring
progress in goals specifically iden2fied by the pa2ent

•  While on the surface it just sounds like a discussion, it

requires inten2onal and skilled guidance by the therapist
using techniques, such as Mo2va2onal Interviewing.

•  It is a very specific process / method / tool

35

Kim Frey, Oregon, 10/12/18

 Step 2: Set Goals – Goal Attainment Scale
Goal 1 Goal 2 Goal 3
Level of Run a half marathon by
November 1st
A*ainment
Much more than Run 13.1 miles
expected
+ 2

Somewhat more Run 9 miles at a Kme

than expected
+ 1

Expected level of Run 6 miles at a Kme

outcome
0

Somewhat less Run 3 miles at a Kme

than expected
- 1

Much less than Can’t run a full mile

expected
- 2

Johnson, S & Frey, K, ASHA, Denver, CO, 2015 Kim Frey, Oregon, 10/12/18
 GAS: Purpose – Why relevant in Inpatient

•  To facilitate discussion about what is important to the

patient and/or family

•  To help the patient and therapist identify where the

patient is currently functioning and where they
want to be functioning (WHAT NEED TO DO)

•  For the patient to understand what he specifically

and concretely needs to do in order to make
progress (HOW GOING TO DO IT)

•  Measures goals specific to the patient, in their terms

Kim Frey, Oregon, 10/12/18

 GAS: How to….
Goal 1
GAS discussion includes….. Level of
A*ainment
1.  Iden2fying goal(s)
Much more
than expected
2.  Defining levels of improvement (towards goal) + 2
and decline (away from goal) Somewhat
more than
expected
3.  Outlining what specifically needs to be done + 1
(steps to take) to achieve that goal Expected level
of outcome

4.  Determining how progress will be 0

measured Somewhat less

than expected
- 1
5.  Establishing how to ensure follow-through (Baseline)

with steps to achieve progress Much less than

expected
- 2
38

Kim Frey, Oregon, 10/12/18

 GAS – how to…

Motivational Interviewing Goal Attainment Scaling

39

Kim Frey, Oregon, 10/12/18

 Motivational Interviewing (MI)

Premise: A mindful conversation used to help us better

understand, elicit, and strengthen someone’s motivation for
change – usually when when we encounter resistance or
ambivalence
•  Appears simple, but requires much practice.
•  Provides concrete strategies for the MI spirit:
•  Collaborating: Teamwork; client is expert of himself
•  Evocation: Drawing out ideas and solutions from the client
•  Autonomy: Decision making left to the client.
•  Engaging the person: Eliciting and strengthening someone’s own
motivation
•  Ask questions, don’t tell: Listen more than 50% of the time.
•  Requires training, feedback, and coaching by MI trainers
(www.motivationalinterviewing.org)
40
Miller RW, Rollnick S. Mo2va2onal interviewing: preparing people to change addic2ve behavior. New
Kim Frey, Oregon, 10/12/18 York, NY: The Guilford Press; 1991.
 MI Principles
R.U.L.E O.A.R.S
R: Resist the righting reflex O: Open ended questions
•  Don’t try to actively fix client’s •  invite more than one word
problems . answers, can’t be answered with
yes or no
U – understand your client’s motivation.
A: Affirmations
•  Motivation comes from the client.
•  recognize positive qualities,
•  We can facilitate motivation. strengths and efforts; reinforce
what someone is doing well
L - Listen
•  Empathy – try to understand client’s R: Reflections
attitude •  simple (paraphrasing) and
complex (getting at the feeling or
E - Empower your client meaning)
•  “All change is self-change” S: Summarize
•  Be hopeful about the possibility of •  restating what you heard, so they
change for client FEEL HEARD, and if there is a
plan, review what that is and
what each person’s role will be
41
Rosengren, D.B. (2009). Building Mo2va2onal Interviewing Skills: A prac22oner workbook. New York, NY: The
Kim Frey, Oregon, 10/12/18 Guilford Press
GAS: how to in the inpatient rehab setting

Kim Frey, Oregon, 10/12/18

 Common Inpatient Goals

Structure of GAS-facilitated Pt/Family Goals:

conversation
“What are the most important things for “Nothing. I’m fine.”
you to work on? (General goal)
“get out of this bed”
“Scale of 0-10, how would you rate ___
before __ and now __?” (Specific goal)
“Nothing is different, I’m just tired and
“Times you notice your ___ is if I slept in my own bed I’d be fine.”
better?” (Behavior change)
“When you leave here, what would you
“Get rid of this belt on me”
like ____ to be?”
“get to therapies on my own”
“How often could you use strategy to
improve ____.” (Implement change) “go home”
“What a little better or a little worse look
like?” (Scaling for progress) “go back to work”

“be there for the kids” 43

Kim Frey, Oregon, 10/12/18

 Case study 1: Background

Age: 65 year old male

Diagnosis: cognitive-communication disorder

Etiology: R CVA

Neuroimaging:

•  Large right hemisphere hemorrhagic bleed

extending from frontal to parietal regions

Time since injury: 2 months

Social: married and retired

Kim Frey, Oregon, 10/12/18

 Case study 1: Cog- comm problems / strengths

Presenting problems
•  Left inattention
•  Decreased initiation
•  Some irritability and uninsightful
•  2 person transfer
•  Disinhibited
Strengths
•  Insight into needing help with transfers
•  Willing to engage in conversation and goal setting
•  Motivated with desire to be less of a burden on his
wife

Kim Frey, Oregon, 10/12/18

 Case study 1: Step 1: Assessment
Step 2: Goal setting
Patient goal status: Unsure about goals, Initiation,
and irritability: doesn’t know what to focus on, slow/
no initiation and people don’t engage him in transfers
•  Quantify why he needs to lean forward – end goal
•  Quantify where he is currently with degrees leaning
forward
•  Quantify how far needs to lean to help with dressing
•  Goal: he leans to certain degrees
Goal support
•  Engaging him in conversation about goals
•  Writing information on wipe-off board
•  Validating his efforts and skills and goals
•  Identifying specific level of change and behaviors

Kim Frey, Oregon, 10/12/18

 Case study 1: Step 2: Goal Attainment Scale
Goal 2: INDEPENDENCE Goal 2: INDEPENDENCE
“1 person help transfer and he does “1 person help transfer and he does
Level of Attainment more.” more.”

Patient will get to 90 degrees leaning

forward

Much more than Patient flexes forward 90 degrees

expected
+2

Patient flexes forward 93 degrees

Somewhat more
than expected
Improvement

+1

Expected level of Patient flexes forward 96 degrees

outcome
0

Somewhat less than Patient flexes forward 100 degrees

expected
-1
(Baseline)
Decline

Much less than Patient flexes forward 110 degrees

expected 47
-2 Kim Frey, Oregon, 10/12/18
 Case study 2: Background

Age: 33 year old male

Diagnosis: moderate TBI,
currently Rancho VI
Etiology: fall off bicycle
Neuroimaging:
•  Left subdural hematoma, 4mm in thickness over the frontal lobe, less thick
posteriorally
•  Additional blood in the subarachnoid space at the level of the sylvian fissure
•  Largest hematoma in mid left temporal lobe
•  Subdural parallel to the left lateral surface of the interhemispheric fissure

Time since injury: 9 days

Social: married and is a teacher

Kim Frey, Oregon, 10/12/18

 Case study 2: Cog- comm problems / strengths

Presen#ng problems
•  conduc2on aphasia – fluent, poor repe22on
•  phonemic dysfluencies
•  phonemic dyslexia and dysgraphia
•  impaired working memory and declara2ve memory – poor, and
uninsighnul, recollec2on of conversa2ons
•  Disinhibited
Strengths
•  insight into verbal and wriFen expressive struggles
•  independent follow through
•  improving safety

Kim Frey, Oregon, 10/12/18

 Case study 2: Step 1: Assessment &
Step 2: Goal setting
Assessment:
•  O-Log
•  BNT
•  WAB
•  RANDT
Goal setting (begin with the end):
•  Go back to work
•  What need to be able to do to go back to work
•  Likert scale rating

Kim Frey, Oregon, 10/12/18

Case study 2: Step 2: Goal identification

Kim Frey, Oregon, 10/12/18

 Case study 2: How to approach goals
•  Word finding / fluency: conduc2on aphasia and speaks quickly
•  Quan2fy how open he speaks fluidly
•  Define strategies he uses when he does speak fluidly
•  Make him aware of execu2ng those strategies

•  Impaired reading comprehension / phonemic-orthographic
conversion
•  Quan2fy what level he can read

•  Impaired working memory: because slow auditory processing,
he misinterprets and misses conversa2on with wife
•  Quan2fy with wife how frequently he misses conversa2on
•  Define types of info he misses
•  Define contexts in which he misses

Kim Frey, Oregon, 10/12/18

Case study 2: Step 2: Goal Attainment Scale

Improving

Start
Worsening

Kim Frey, Oregon, 10/12/18

Case study 2: Step 2: Goal identification

Kim Frey, Oregon, 10/12/18

 Case study 3: Background

Age: 20 year old female

Diagnosis: Severe TBI, GCS unknown
Currently: Rancho VII (AutomaKc-Appropriate)
EKology: Car accident
Neuroimaging:
•  Right subdural hematoma with subarachnoid hemorrhage and hernia2on
Time since injury: 15 weeks
Educa2on/Employment: student / Junior in college
CogniKve-CommunicaKon Status:
•  Challenges: decreased iniKaKon, impaired working and episodic memory
•  Strengths: resolving aphasia, engaged, remembers therapists names from
Friday to Monday, insight into brain injury
Values / Interests:
•  Very social 55
•  Building relaKonships important to her; loves telling stories
Kim Frey, Oregon, 10/12/18
 Case study 3: How to approach goals

•  IniKaKon: slow iniKaKon and so people don’t give her Kme to

engage
•  QuanKfy how o\en she successfully engages with people.
•  QuanKfy how long it takes her to iniKate when she is
successful and how long when she’s not.
•  Establish a goal Kme frame for iniKaKon or a number of
iniKaKons.
•  Impaired working memory: because of either word finding
challenges or slow processing, she loses track of the convo
•  QuanKfy how o\en she successfully keeps up or loses track
of convo
•  Brainstorm strategies for how to be successful in convo w/
regard to following the conversaKon (e.g., noKce when she
loses track of convo and ask for repeKKon)

Kim Frey, Oregon, 10/12/18

 Case study 3: How to approach goals

•  DeclaraKve memory : either because of slowed processing or

aphasia she loses track of details (e.g., people’s names,
conversaKons, treatment instrucKons)
•  Put remembering new people’s names into her own words,
e.g., “catch people’s names”?
•  Id if there are Kmes she is successful catching people’s
name in hallway/bistro
•  QuanKfy how many names she would like to catch in a day /
what is a reasonable goal?
•  Brainstorm strategies for remembering names (e.g., she
stops and asks them to repeat it and she repeats it 3 Kmes;
she asks her tech/nurse to write name in her planner; she
takes a pic of person with her iPad).

Kim Frey, Oregon, 10/12/18

 Case study 3: How to approach goals

GENERAL GOAL:
I want to be able to keep
rela2onships with my family
and friends

Pa2ent-centered
SPECIFIC GOAL:
I want to be able to remember
details of my day

Contextually-relevant
COGNITIVE-COMMUNIATION
GOAL
I want to remember the names
of people that say hi to me in
the hallway or in the bistro.
58

Kim Frey, Oregon, 10/12/18

 Case study 3: Goal Attainment

In order to build rela2onships in the hospital, I will ask
Level of A*ainment
people I meet in the hallway to repeat their names for
me 100% of opportuni2es.

Much more than expected I ask people I meet in the hallway to repeat
+ 2 their names (99%) of opportuni2es.
Somewhat more than
expected
I ask people I meet in the hallway to
+ 1 repeat their names (66%) of opportuni2es.

Expected level of outcome I ask people I meet in the hallway to

0 repeat their names (33%) of opportuni2es.
Somewhat less than
expected I ask people I meet in the hallway to
-  1 repeat their names (0%) of opportuni2es.
(Baseline)

Much less than expected I don’t show interest in anyone in the

- 2 hallways here at Craig. 59

Kim Frey, Oregon, 10/12/18

Thoughts?
 Case study 4: Background
Age: 37 year old male
Diagnosis: Severe TBI, GCS unknown
Currently: Rancho VII (Automatic-Appropriate)
Etiology: Fall
Neuroimaging:
•  Right subdural hematoma with subarachnoid hemorrhage and herniation
•  Left temporal contusion
Time since injury: 15 weeks
Living situation: Married with daughter and step-daughter
Education/Employment: 12 years, mechanic
Cognitive-Communication Status:
Challenges: anomic aphasia, inattentive, disinhibited, decreased insight.
Strengths: fluent, resolving aphasia, engaged, some insight
61

Kim Frey, Oregon, 10/12/18

 Case study 4: Step 2: Establish goals

Kim: You’re doing great and you want to get home. There are a lot of things to work on
here and we’d like to iden2fy something specific, something that’s important for you to
work on . I’d like to talk with you about that a liFle is that ok? Start by telling me a liFle
about yourself and what you want to work on?

Pt: I have a daughter and a step-daughter and I talk to them every morning and every
night. Since this fall I want to get back to them, get back to being a good dad. But this girl
here, this bull dog, she’s been teaching me a lot, and I’ve been listening to her. I do
every2ng she says to do because that’s who I am. I’m an early riser and my family keeps
asking me how I’m going to get back to being a good dad and when I’m going to get out of
here, and I tell them let me do my thing here, I mean I want to get out, but I have things to
do here, a schedule to follow. And they are making me wear this belt, but I get it, I have to
respect them. I mean I don’t want to because I’m not lame, I mean I’m strong, I go to the
gym every day and work out. I have a lot of pride to be honest, and I’m a talker, like before
this, with the ladies, I was a smooth talker. Ya know in life, respect is what it’s all about,
you goFa have respect, or bam, I just wanna sock you, but I know I can’t.

Kim Frey, Oregon, 10/12/18

 Case study 4: Step 2: Establish goals

Kim: I’m sorry to interrupt. You work really hard at everything you do, you’re always all in.
And your family is important – your daughters, and being a good dad and gaining the
respect of your friends. Tell me more about….

Pt: Oh yah because I was in Durango and met this guy and he had had a brain injury and
then he got into a fight and pissed the other guy off so much that they guy punched him
and he died. And so I awlays get people’s respect and not pop off but there are 2mes
when, like if my duaghter brings a guy home I don’t like, or he doesn’t treat her good, I’m
gonna let him know, ya know. He’s goFa teat my daughter right, respect her. I treat
people really well ya know, let people know who I like, they can tell, and if I don’t like you,
well then I don’t give you the 2me of day, I let people know who I like, they can tell, an if I
don’t like you, well then I don’t give you the 2me of day.
Kim: On one hand, you know what to do to let people know you like them, and on the
other hand, you have things you do to let someone know you don’t like them.

Pt: “Oh yah, people know when I do or don’t like them by the way I talk to them.”

Kim Frey, Oregon, 10/12/18

 Collaboration

1)  What types of informa2on would be helpful in this

conversa2on to help shape goals and how we will get
there?
•  Who is important to him?
•  What are his character traits
•  Anything that shows he’s got buy in/willingness to
change?
•  Nuggets to help inform the goal

2)  What types of goals?

Kim Frey, Oregon, 10/12/18

 Case study 4: Step 2: IDENTIFY goals

Kim: You’re doing great and you want to get home. There are a lot of things to work on
here and we’d like to iden2fy something specific, something that’s important for you to
work on . I’d like to talk with you about that a liFle is that ok? Start by telling me a liFle
about yourself and what you want to work on? (open-ended ques2on)

Pt: I have a daughter and a step-daughter and I talk to them every morning and every
night. Since this fall I want to get back to them, get back to being a good dad. But this girl
here, this bull dog, she’s been teaching me a lot, and I’ve been listening to her. I do
everything she says to do because that’s who I am. I’m an early riser and my family keeps
asking me how I’m going to get back to being a good dad and when I’m going to get out of
here, and I tell them let me do my thing here, I mean I want to get out, but I have things
to do here, a schedule to follow. And they are making me wear this belt, but I get it, I
have to respect them. I mean I don’t want to because I’m not lame, I mean I’m strong, I
go to the gym every day and work out. I have a lot of pride to be honest, and I’m a talker,
like before this, with the ladies, I was a smooth talker. Ya know in life, respect is what it’s
all about, you goHa have respect, or bam, I just wanna sock you, but I know I can’t.

Who is important Goal Nuggets help inform goal

Kim Frey, Oregon, 10/12/18 Character traits Buy in/willingness to change
 Case study 4: Step 2: IDENTIFY goals

Kim: I’m sorry to interrupt. You work really hard at everything you do, you’re always all in.
And your family is important – your daughters, and being a good dad and gaining the
respect of your friends. Tell me more about…. (affirma2on)

Pt: Oh yah because I was in Durango and met this guy and he had had a brain injury and
then he got into a fight and pissed the other guy off so much that they guy punched him
and he died. And so I always get people’s respect and not pop off but there are 2mes
when, like if my daughter brings a guy home I don’t like, or he doesn’t treat her good, I’m
gonna let him know, ya know. He’s goHa treat my daughter right, respect her. I treat
people really well ya know, let people know who I like, they can tell, and if I don’t like
you, well then I don’t give you the 2me of day.

Kim: On one hand, you know what to do to let people know you like them, and on the
other hand, you have things you do to let someone know you don’t like them. (reflec2on)

Pt: “Oh yah, people know when I do or don’t like them by the way I talk to them.”

Who is important Goal Nuggets help inform goal

Kim Frey, Oregon, 10/12/18 Character traits Buy in/willingness to change
 Case study 4: Step 2: IDENTIFY goals

Kim: “You know how to change the way you interact with someone to give them the
impression that you care about them, or are interested in them.” (reflec%on)

Pt: “Oh yah, because I need to teach my daughter how to be respecWul. Take my mom and
my dad. My mom is amazing. She makes you feel super important and like she always
wants to be around you. But my dad, he’s a grade A asshole. He yelled a lot and ….”

Kim: “I’m sorry to interrupt. I’d like to ask you a ques2on about something you just said, is
that ok?.” (open-ended ques%on)

Pt: “Of course.”
Kim: “You can tell when someone is respec#ng you, being nice to you, and when someone
isn’t.” (reflec%on)
“I wonder what someone who isn’t respec#ng you acts like?.”(wipe off board) (elicita%on)

Pt: “Oh yah, my dad, he would yell a lot, you couldn’t even get a word in, it was always his
way or the highway and he didn’t want to hear anything else from anyone.”

Who is important Goal Nuggets help inform goal

Kim Frey, Oregon, 10/12/18 Character traits Buy in/willingness to change
 Case study 4: Step 2: IDENTIFY goals

Kim: “Your dad didn’t listen or give you the chance to talk.” (reflec%on)

Pt: “Hell no. All he cared about was himself.”
Kim: “And your mom is amazing and makes you feel like she respects you and listens.
(reflec%on). Tell me a liFle about what she does so you can tell she respects you and
listens.” (wipe off board) (elicita%on)
Pt: “Oh ya. She always asks you ques2ons. Like me, I always ask ques#ons too, that’s how
you get people’s respect. And she’s really thoughWul, she thinks about what she’s talking
to you about, like she’s not gonna ask you ques2ons about something you don’t like or
that would piss you off. She thinks about what she’s saying before she says it and that
makes people really like her and when I leave here, I goFa get back to work, to my family,
and when I talk with my daughter every night, I’m always asking her, “how was your day,
and “how are the boys”, “are they trea2ng you well?” cause if they’re not, you goFa stay
away from them, they goHa respect you, and then some2mes I like to just hang out with
my daughter, ya know, we sit and watch Sponge Bob, even though I don’t really want to
watch Sponge Bob, but that’s what she wants to do so I’m like ok, let’s do that cause I want
to be her friend and a role model for her, and…”

Who is important Goal Nuggets help inform goal

Kim Frey, Oregon, 10/12/18 Character traits Buy in/willingness to change
 Case study 4: Step 2: IDENTIFY goals

Kim: “Would it be ok if I summarize a bit? (wipe off board). You no2ce there are some
differences in you since your fall. And you are super dedicated to working on those things
because that’s just who you are. Making sure you have the respect of your family and
friends is really important to you and you want to be a role model for your daughter. You
no2ce things that people do, like your mom and dad, that make you really like them,
things they do that make you respect them. The good things being listening and stopping
and thinking before they say something . (summary)
Pt: “Absolutely”.

Kim: “Can I ask, on a scale of 1-10, how important would you say stopping and listening is
to gaining people’s respect?” (scaling ques2on)

Pt: “Oh a 10 You really need to be able to listen to people in order to represent yourself
and gain people’s respect. And I really think….”.
Kim: “Joe, I’m looking at the clock and our 2me is running down, and so would it be ok if I
keep us talking about this topic because our goal here is to come up with something
specific to work on and you’re given us some great info?”

Who is important Goal Nuggets help inform goal

Kim Frey, Oregon, 10/12/18 Character traits Buy in/willingness to change
 Case study 4: Step 2: IDENTIFY goals

Pt: “Absolutely”.
Kim: “Your goal is to get out of here and it’s really important is for you to do things that
keeps your pride up, that makes people respect you – so important, you’ve rated it a 10.
You’ve no2ced that your mom does things like stop and listen a^er she asks you a
ques#on and that makes you feel good. Since you no2ce that gets you to respect her can I
ask you a ques2on?” (summary)
Pt: “Of course.”
Kim: “Oh a scale of 0-10, how open would you say that you stop and listen to people’s
responses during conversa2ons?” (scaling ques2on)

Pt: “Oh I ask people ques2ons all the 2me, so that’s goFa be a 10.”.
Kim: “Ok, you do ask people ques2ons. What happens aper the ques2on? How open
would you say you stop and listen to responses…put the brakes on you?” (evoking
ques2on)
Pt: “Oh I think that’s a 10 too, I mean I dunno, maybe a 7”.

Who is important Goal Nuggets help inform goal

Kim Frey, Oregon, 10/12/18 Character traits Buy in/willingness to change
 Case study 4: Step 2: IDENTIFY goals

Kim: “Ok, you no#ce that you do put the brakes on some#mes, but not all the
#me.” (summary)
Pt: “Yah, but I dunno, I dunno if that’s right or not. Kelly what would you say?”
Kim: “Before she answers, in the interest of 2me, you’re interested in geung the
perspec2ve of other people? Maybe because you care very deeply about what other
people think, about how you come across to other people. I wonder what other people in
addi2on to Kelly might think?” (evoking ques2on)
Pt: “Well we could ask them.”
Kim: “Oh! We could ask other people in the hospital about how o^en you put the brakes
on. Who might that be?” (evoking ques2on)
Pt: “My brother Dave, my therapists, my nurses.”
Kim: “Ok great. You’ve got a list of people we could ask. Would it be ok if tomorrow we
come up with a plan for asking those other people about how o^en they experience you
pucng the brakes on, stopping and listening as a way of showing them respect?
Pt: “Of course. That’s important.”
Who is important Goal Nuggets help inform goal
Kim Frey, Oregon, 10/12/18 Character traits Buy in/willingness to change
 Buy in/willing to Nuggets to
Character traits change inform goal Goal
•  Talk to her every •  Been listening to •  Want to get back •  I always ask •  be a role model
morning her every day to her ques2ons too, for my daughter.
•  I listen to her b/c (therapist) •  a lot of pride that’s how you get •  We could ask
that’s who I am •  I have things to do •  respect is what it’s people’s respect. other people in the
•  Early riser here, a schedule all about, you •  She’s really hospital about
•  I go to the gym to follow goFa have respect thoughnul, she how oOen you put
every day and •  just wanna sock •  always get thinks about what the brakes on.
work out. have to you, but I know I people’s respect. she’s talking to •  Who might that
respect them can’t. •  I treat people you about, be?
•  He’s goFa treat •  Making sure you really well ya •  She thinks about •  ok if tomorrow we
my daughter right, have the respect of know, let people what she’s saying come up with a
respect her. your family and know who I like, before she says it plan for asking
•  super dedicated to friends is really they can tell and that makes those other people
working on those important to you •  need to teach my people really like about how oOen
things because •  10 You really need daughter how to her they experience
that’s just who you to be able to be respecnul •  There are things you puQng the
are listen to people in •  You can tell when that people do brakes on,
order to represent someone is •  listening and stopping and
yourself and gain respec2ng you, stopping and listening as a way
people’s respect being nice to you thinking before of showing them
•  Kelly what would •  I wonder what they say respect
you say someone who isn’t something
•  Well we could ask respec2ng you •  you no2ce that
them acts like? you do put the
•  you couldn’t even brakes on
get a word in some2mes, but
not all the 2me

Kim Frey, Oregon, 10/12/18
 Case study 4: Step 2: Goals now what

GENERAL GOAL:
I want to get out of here
and get home and back to
work and friends and
family

Pa2ent-centered
SPECIFIC GOAL:
I want to be respected and
be a good role model for
my daughter

Contextually-relevant
COGNITIVE-
COMMUNIATION GOAL
I want to be sure I stop and
listen to people’s
responses in conversa2on.
73

Kim Frey, Oregon, 10/12/18

 Case study 4: How to approach goals

•  Disinhibited: talks so much (pressed speech) that he can’t put the

brakes on his talking and dominates the conversaKon
•  QuanKfy, using other people, how much he is dominaKng the
conversaKon
•  IdenKfy Kmes when he does successfully put the brakes on his
talking
•  Write out strategies for him to, in the moment, put the brakes on
•  Impaired working memory / a*enKon: because he talks so much he
loses track of what he is saying
•  QuanKfy, via wri*en transcript, how o\en he stays on topic, vs
gets off topic
•  Write out strategies (internal or external cues) for him to
remember to stay on topic, or keep his answers short, or directly
state he lost track of what he was saying.

Kim Frey, Oregon, 10/12/18

 Case study 4: How to approach goals

•  Word finding challenges: when he can’t find a word, he gets

derailed causing him to talk even more
•  Write out some very short “scripts” and include chosen
vocabulary for him to prac2ce (e.g., social scripts so he
doesn’t dominate the convo)
•  Prac2ce strategy for id’ing when he can’t come up with a
word and how to handle so he doesn’t get derailed

•  Extreme fa2gue: He talks so much, feels like he has to be “on,

perform” all the 2me and so is exhuasted at night.

Kim Frey, Oregon, 10/12/18
 Case study 4: Step 2: GAS

I will stop and listen to people’s responses at least
Level of A*ainment 100% of opportuni#es

Much more than expected I stop and listen to people’s responses 100%
+ 2 of opportuni2es.
Somewhat more than
expected
I stop and listen to people’s responses 90%
+ 1 of opportuni2es.

Expected level of outcome I stop and listen to people’s responses 80%

0 of opportuni2es.
Somewhat less than
expected I stop and listen to people’s responses 70%
-  1 of opportuni2es.
(Baseline)

Much less than expected I never stop and listen to people’s

- 2 responses.
76

Kim Frey, Oregon, 10/12/18

 Case study 5: Background
Goal:
•  I want to tell my wife about my day when she comes here aper work.
•  I want to be able to get myself to therapies
Barriers to going home:
•  At the end of the day, I can’t remember what I’ve done.
•  Limited ini2a2on and distractability
Frustra#on:
•  My wife gets frustrated with me and we get in an argument because she says I’m
not listening well enough in therapies. I don’t like to argue but I can’t remember
what I did that day. All the things run together. And my therapies are so busy we
don’t review what we did at the end.
•  People think I can’t do things on my own

Final Speech goal:

•  Write in his planner
•  Communicate to therapist need to allow 2me to write in planner
•  Ini2ate going to therapies on his own

Kim Frey, Oregon, 10/12/18

 Case study 5: Step 1: Assessment &
Step 2: Goal setting
Assessment:
•  O-Log
•  BNT
•  WAB
•  RANDT
Goal secng (begin with the end):
•  Go back to work
•  What need to be able to do to go back to work
•  Likert scale ra2ng
Kim Frey, Oregon, 10/12/18
 Case study 5: How to approach goals
•  Slow processing and declara#ve memory: can’t keep up in
conversa2ons and misses / forgets details
•  Quan2fy how open he writes in his planner aper therapies
•  Quan2fy how much of sessions he remembers/writes
accurately

•  Poor ini#a#on: Gets distracted during the day and doesn’t
ini2ate going to therapies:
•  Quan2fy what things he gets distracted by
•  Quan2fy how open he ini2ates going to therapies
•  Iden2fy cueing strategy to act as his “igni2on” to ini2ate
going to therapies
•  Quan2fy how open he uses that cueing strategy


Kim Frey, Oregon, 10/12/18
 Case study 5: Step 2: Goal Attainment Scale
Goal 2: INDEPENDENCE Goal 2: INDEPENDENCE
“I want to tell my wife about my day.” “I want to come to therapies on my
Level of Attainment own.”

Patient will use memory strategy of Patient will successfully come to

note-taking after all therapy activities therapies alone

Much more than Patient writes a note in his planner after I get distracted during day and remember
expected 6/6 scheduled therapy activities (100%) to go to 6/6 therapies on my own
+2

Patient writes a note in his planner after I get distracted during day and remember
Somewhat more
4/6 scheduled therapy activities (67%) to go to 4/6 therapies on my own
than expected
Improvement

+1

Expected level of I get distracted during day and remember

Patient writes a note in his planner after
outcome to go to 2/6 therapies on my own
2/6 scheduled therapy activities (33%)
0

Somewhat less than Patient writes a note in his planner after I get distracted during day and remember
expected 0/6 scheduled therapy activities (0%) to go to 0/6 therapies on my own
-1
(Baseline)

I get angry because I miss therapies

Decline

Much less than Patient does not use his planner at any
expected point throughout the day. 80
-2 Kim Frey, Oregon, 10/12/18
 Step 3: Treatment construction

FINALLY WHAT DOES THIS LOOK LIKE IN MY TREATMENT

SESSION?

Kim Frey, Oregon, 10/12/18

 Step 3: Treatment

Ø  Specificity
Ø  Number of repe##ons / opportuni#es for prac#ce
Ø  Consistent approaches to the task
Ø  Focus on strengths and strategies for success
Ø  Establish a criterion / level of skill acquisi#on
Ø  Treatment tasks are relevant to and occur in the
person’s current context
Ø  Treatment tasks are or as close as possible to the
real-life goal

Kim Frey, Oregon, 10/12/18

Treatment choices

Kim Frey, Oregon, 10/12/18

 Functional therapy

Kim Frey, Oregon, 10/12/18

 5 Treatment parameters
Byng and Black (1995)

1.  Focus of therapy / Goal – what tasks are aiming to do

2.  Context – where is treatment occurring

3.  Materials – types of items or structures used in therapy

4.  Task – what is done in the therapy session

5.  Support / Cues – how therapist facilitates successful

responses or gives feedback.

Johnson, S & Frey, K, ASHA, Denver, CO, 2015 Kim Frey, Oregon, 10/12/18
 Treatment construction
Goal Context Materials Task Support / Cues

1.

2.

3.

Johnson, S & Frey, K, ASHA, Denver, CO, 2015 Kim Frey, Oregon, 10/12/18
 Case study 1: Step 1: Assessment
Step 2: Goal setting
Patient goal status: Unsure about goals, Initiation,
and irritability: doesn’t know what to focus on, slow/
no initiation and people don’t engage him in transfers
•  Quantify why he needs to lean forward – end goal
•  Quantify where he is currently with degrees leaning
forward
•  Quantify how far needs to lean to help with dressing
•  Goal: he leans to certain degrees
Goal support
•  Engaging him in conversation about goals
•  Writing information on wipe-off board
•  Validating his efforts and skills and goals
•  Identifying specific level of change and behaviors

Kim Frey, Oregon, 10/12/18

 Case study 1: Step 2: Goal Attainment Scale
Goal 2: INDEPENDENCE Goal 2: INDEPENDENCE
“1 person help transfer and he does “1 person help transfer and he does
Level of Attainment more.” more.”

Patient will get to 90 degrees leaning

forward

Much more than Patient flexes forward 90 degrees

expected
+2

Patient flexes forward 93 degrees

Somewhat more
than expected
Improvement

+1

Expected level of Patient flexes forward 96 degrees

outcome
0

Somewhat less than Patient flexes forward 100 degrees

expected
-1
(Baseline)
Decline

Much less than Patient flexes forward 110 degrees

expected 88
-2 Kim Frey, Oregon, 10/12/18
 Case study 2:Treatment construction

Goal Context Materials Task Support / Cues

1. Get to 90 degree Room Mirror 1.  Co-tx with OT / PT 1.  MulK-sensory input
flexion Gym Drawings 2.  He bends bendy thing for sensory 2.  Drawings on wipe
Bendy things input board
Camera 3.  He bends in front of large mirror 3.  Talk about him
4.  Take pictures of what he looks like “feeling” what is it to
bending bend
5.  He writes in a “bending chart” how 4.  Wri*en support from
many degrees he bend on that day. chart

Kim Frey, Oregon, 10/12/18

 Case study 2: Background

Age: 33 year old male

Diagnosis: moderate TBI,
currently Rancho VI
Etiology: fall off bicycle
Neuroimaging:
•  Left subdural hematoma, 4mm in thickness over the frontal lobe, less thick
posteriorally
•  Additional blood in the subarachnoid space at the level of the sylvian fissure
•  Largest hematoma in mid left temporal lobe
•  Subdural parallel to the left lateral surface of the interhemispheric fissure

Time since injury: 9 days

Social: married and is a teacher

Kim Frey, Oregon, 10/12/18

Case study 2: Step 2: Goal Attainment Scale

Improving

Start
Worsening

Kim Frey, Oregon, 10/12/18

 Case study 2:Treatment construction

Goal Context Materials Task Support / Cues

1. Improve speech Office PaKent’s book 1.  Oral reading of sentences in book 1.  Remind pt to slow
fluency pace of talking
2.  Discussion

2. Improve reading Office PaKent’s book 1.  Pt read paragraph in book 1.  Remind pt to a*end
comprehension 2.  Discussion to small words that
change the meaning
of the sentence

3. Improve memory Office PaKent’s book 1.  Review notes he has wri*en down 1.  Discuss double
for conversaKons day Wife in his book from conversaKons meaning words
to day 2.  You have conversaKon about topics 2.  Discuss his
listed in his file perspecKve on taking
3.  First, he take notes word for word notes following
4.  Then he take general notes and conversaKon
re-tell
5.  Educate wife about
communicaKon break-downs
Kim Frey, Oregon, 10/12/18
 Case study 3: Background

Age: 20 year old female

Diagnosis: Severe TBI, GCS unknown
Currently: Rancho VII (AutomaKc-Appropriate)
EKology: Car accident
Neuroimaging:
•  Right subdural hematoma with subarachnoid hemorrhage and hernia2on
Time since injury: 15 weeks
Educa2on/Employment: student / Junior in college
CogniKve-CommunicaKon Status:
•  Challenges: decreased iniKaKon, impaired working and episodic memory
•  Strengths: resolving aphasia, engaged, remembers therapists names from
Friday to Monday, insight into brain injury
Values / Interests:
•  Very social 93
•  Building relaKonships important to her; loves telling stories
Kim Frey, Oregon, 10/12/18
 Case study 3: How to approach goals

•  Declarative memory : either because of slowed

processing or aphasia she loses track of details (e.g.,
people’s names, conversations, treatment instructions)
•  Put remembering new people’s names into her own
words, e.g., “catch people’s names”?
•  Id if there are times she is successful catching
people’s name in hallway/bistro
•  Quantify how many names she would like to catch in a
day / what is a reasonable goal?
•  Brainstorm strategies for remembering names (e.g.,
she stops and asks them to repeat it and she repeats
it 3 times; she asks her tech/nurse to write name in
her planner; she takes a pic of person with her iPad).

Kim Frey, Oregon, 10/12/18

 Case study 3: Goal Attainment

In order to build rela2onships in the hospital, I will ask
Level of A*ainment
people I meet in the hallway to repeat their names for
me 100% of opportuni2es.

Much more than expected I ask people I meet in the hallway to repeat
+ 2 their names (99%) of opportuni2es.
Somewhat more than
expected
I ask people I meet in the hallway to
+ 1 repeat their names (66%) of opportuni2es.

Expected level of outcome I ask people I meet in the hallway to

0 repeat their names (33%) of opportuni2es.
Somewhat less than
expected I ask people I meet in the hallway to
-  1 repeat their names (0%) of opportuni2es.
(Baseline)

Much less than expected I don’t show interest in anyone in the

- 2 hallways here at Craig. 95

Kim Frey, Oregon, 10/12/18

 Case study 3:Treatment construction

Goal Context Materials Task Support / Cues

1)  Write script / pracKce what to 1)  ID specific goal

1.  Independence Room •  iPad alarm say when she meets people 2)  Role playing
Hallway •  Nursing tech in the hallway 3)  Repeated pracKce of
Asking people to repeat •  Planner or 2)  PracKce her stopping people logging people’s names
their names in hallway iPad in the hallway and she tells 4)  Memory strategy
tech to write info in her 5)  CommunicaKon with
planner or in her iPad techs
3)  PracKce memory strategy of
repeaKng person’s name 3
Kmes in that encounter
2.

Kim Frey, Oregon, 10/12/18

 Case study 4: Background
Age: 37 year old male
Diagnosis: Severe TBI, GCS unknown
Currently: Rancho VII (Automatic-Appropriate)
Etiology: Fall
Neuroimaging:
•  Right subdural hematoma with subarachnoid hemorrhage and herniation
•  Left temporal contusion
Time since injury: 15 weeks
Living situation: Married with daughter and step-daughter
Education/Employment: 12 years, mechanic
Cognitive-Communication Status:
Challenges: anomic aphasia, inattentive, disinhibited, decreased insight.
Strengths: fluent, resolving aphasia, engaged, some insight
97

Kim Frey, Oregon, 10/12/18

 Case study 4: Step 2: Goals now what

•  Disinhibited: talks so much (pressed speech) that he can’t put the

brakes on his talking and dominates the conversaKon
•  QuanKfy, using other people, how much he is dominaKng the
conversaKon
•  IdenKfy Kmes when he does successfully put the brakes on his
talking
•  Write out strategies for him to, in the moment, put the brakes on
•  Impaired working memory / a*enKon: because he talks so much he
loses track of what he is saying
•  QuanKfy, via wri*en transcript, how o\en he stays on topic, vs
gets off topic
•  Write out strategies (internal or external cues) for him to
remember to stay on topic, or keep his answers short, or directly
state he lost track of what he was saying.

Kim Frey, Oregon, 10/12/18

 Case study 4: Step 2: GAS

I will stop and listen to people’s responses at least
Level of A*ainment 100% of opportuni#es

Much more than expected I stop and listen to people’s responses 100%
+ 2 of opportuni2es.
Somewhat more than
expected
I stop and listen to people’s responses 90%
+ 1 of opportuni2es.

Expected level of outcome I stop and listen to people’s responses 80%

0 of opportuni2es.
Somewhat less than
expected I stop and listen to people’s responses 70%
-  1 of opportuni2es.
(Baseline)

Much less than expected I never stop and listen to people’s

- 2 responses.
99

Kim Frey, Oregon, 10/12/18

 Case study 4:Treatment construction

Goal Context Materials Task Support / Cues

1)  He gets info from other 1)  ID specific goal

1.  Independence Room •  Other therapists/staff about how 2)  Role playing
Hallway therapists o\en he stops talking and 3)  Repeated pracKce of
Stops talking and Gym •  Planner listens stopping and listening
listens Office •  Phone alarm 2)  IdenKfy some tangible 4)  Reminder strategy
Bistro sensory input reminder to 5)  CommunicaKon with
stop and listen (e.g., rubber therapists/staff
band)
3)  PracKce convo with him
stopping and listening
4)  Create tracking tool that he
tracks progress in planner
a\er sessions
2.

Kim Frey, Oregon, 10/12/18

 Case study (Oh boy): Background
Age: 34 year old male
Diagnosis: Moderate TBI, GCS 9 in ER
Currently: Rancho V (Confused-appropriate)
E#ology: Rock climbing fall
Neuroimaging:
•  Large lep subdural hematoma with mass effect necessita2ng a
lep-sided craniotomy and surgical evacua2on
•  Hemorrhagic contusions of right and lep frontal lobes, R > L
Time since injury: 4 weeks
Living situa#on: married with 2 children
Employment: teacher

Kim Frey, Oregon, 10/12/18

 Case: Oh Boy: Cog- comm problems / strengths

Presenting problems:
•  Fluent aphasia – paraphasias and impaired comprehension
•  Poor memory - inability to recall daily routines
•  Poor attention – difficulty staying focused
•  Impaired safety awareness
•  Impaired independence

Strengths:
•  Recognized people
•  Expressed self with ~ 40% success, 60% paraphasias
•  Could follow simple directions, write and read simple information

Kim Frey, Oregon, 10/12/18

 Case study Oh boy: Step 1: Assessment &
Step 2: Goal setting

Assessment:
•  Chart review –
•  understanding of neuroanatomy
•  social, educational, work history
•  Boston Naming Test
•  Western Aphasia Battery
•  Orientation Log

Goal setting (begin with the end):

-  improve SAFETY by -  _____________

-  improve INDEPENDENCE by -  _____________

Kim Frey, Oregon, 10/12/18
 Example questions Example responses

“What do you want to work on?” “Get the #$!! out of here.”

“What’s geung in the way of you being able to “This stupid belt and nurse that’s with me all the time.”
do that?”

“Geung rid of the belt and your nurse will help you work “They tell me I need to use the call light and follow my
toward geung out of here?” therapy schedule.
They say I need to learn my transfer steps.”
“What can you do to get rid of the belt and nurse?

“Oh. And right now, you’re using your call light how “I use my call light some2mes and know
open or you know how many transfer steps you have?” There are 6 transfer steps.”

“Can we put a number to how open you use the call light “Maybe I use the call light once during the day.
during the day or how many of your transfer steps I don’t don’t do any of my transfer steps”
you know?”

“What does ‘doing a liFle beFer or worse with that “Maybe using my call light 3 2mes during the day.”
look like?”
“Maybe learn at least 3 of my transfer steps”

“How will you measure your progress?” “Write it down on my form”

“How will you remember to keep progressing with “Tell staff/therapists and my family that I want to do this
your goal?” so they can remind me if needed.
Prac2ce the steps with my therapists.”
Kim Frey, Oregon, 10/12/18
 Case study Oh boy: Step 1: Assessment &
Step 2: Goal setting

Assessment:
•  Chart review –
•  understanding of neuroanatomy
•  social, educational, work history
•  Boston Naming Test
•  Western Aphasia Battery
•  Orientation Log

Goal setting (begin with the end): _________________

-  improve SAFETY by - _____________

-  improve INDEPENDENCE by - _____________

Kim Frey, Oregon, 10/12/18

 Case study: Goal Attainment Scaling
Goal: Get rid of behavioral attendant
Goal 1 Goal 1 Goal 2
Level of Safety: Safety: Safety:
AFainment Get rid of 1:1 aFendant Get ride of 1:1 aFendant Remember transfer steps
Uses call light Uses call light

Much more Uses call light 5 of 5 Joe uses call light 100% of Pt transfers from the
than expected opportuni2es during the 2me when needs the nurse chair to bed with stand
+ 2 day by assist
Improvement

Somewhat Joe uses call light at least Pt states at least 4 steps

more than Uses call light 4 of 5
opportuni2es during the 50% of 2me when needs of transfer
expected the nurse
+ 1 day

Pt states at least 2 steps

Expected level Uses call light 2-3 of 5 Joe has a behavior
of transfer
of outcome opportuni2es during the aFendant
day
Somewhat less Pt states 0 steps of
Uses call light 1 of 5 Joe yells for behavior
than expected transfer
opportuni2es during the aFendant
-  1
(Baseline) day

Much less than Uses call light 0 of 5 Joe yells for behavior Pt requires hoyer life
Decline

expected opportuni2es during the aFendant and gets agitated

- 1 day
Kim Frey, Oregon, 10/12/18
 Case study Oh boy: Treatment construction

Goal Context Materials Task Support / Cues

1)  Review steps for the 1)  Simplify steps

1. Safety: Room •  Steps for call light 2)  Errorless
using the 2)  He write each step learning
Use the call call light on index card 3)  Review-Say-Do
light •  Index 3)  Review steps – he
cards put cards in order
4)  Prac2ce using call
light

2.  Safety: Room •  Steps for 1)  Review steps for 1)  Simplify steps
using the transfers 2)  Errorless
Remember Co-tx w/ PT call light 2)  He write each step learning
transfer steps •  Index on index card 3)  Review-Say-Do
cards 3)  Review steps – he
put cards in order
Kim Frey, Oregon, 10/12/18
4)  Prac2ce transfers
 Case study 5: Background
Goal:
•  I want to tell my wife about my day when she comes here aper work.
•  I want to be able to get myself to therapies
Barriers to going home:
•  At the end of the day, I can’t remember what I’ve done.
•  Limited ini2a2on and distractability
Frustra#on:
•  My wife gets frustrated with me and we get in an argument because she
says I’m not listening well enough in therapies. I don’t like to argue but I
can’t remember what I did that day. All the things run together. And
my therapies are so busy we don’t review what we did at the end.
•  People think I can’t do things on my own
Final Speech goal:
•  Write in his planner
•  Communicate to therapist need to allow 2me to write in planner
•  Ini2ate going to therapies on his own

Kim Frey, Oregon, 10/12/18

 Case study 5: Step 2: Goal Attainment Scale
Goal 2: INDEPENDENCE Goal 2: INDEPENDENCE
“I want to tell my wife about my day.” “I want to come to therapies on my
Level of Attainment own.”

Patient will use memory strategy of Patient will successfully come to

note-taking after all therapy activities therapies alone

Much more than Patient writes a note in his planner after I get distracted during day and remember
expected 6/6 scheduled therapy activities (100%) to go to 6/6 therapies on my own
+2

Patient writes a note in his planner after I get distracted during day and remember
Somewhat more
4/6 scheduled therapy activities (67%) to go to 4/6 therapies on my own
than expected
Improvement

+1

Expected level of I get distracted during day and remember

Patient writes a note in his planner after
outcome to go to 2/6 therapies on my own
2/6 scheduled therapy activities (33%)
0

Somewhat less than Patient writes a note in his planner after I get distracted during day and remember
expected 0/6 scheduled therapy activities (0%) to go to 0/6 therapies on my own
-1
(Baseline)

I get angry because I miss therapies

Decline

Much less than Patient does not use his planner at any
expected point throughout the day. 109
-2
Kim Frey, Oregon, 10/12/18
 Case study 5:Treatment construction

Goal Context Materials Task Support / Cues

1)  Type out reminder for him 1)  Simplify steps

1.  Independence: Room •  Laptop to share with OT/PT about 2)  Written / visual
Gym •  Paper his goal of writing cognitive supports
Use memory Office •  Memory 2)  Do a task and practice he (communication
strategy of writing planner writing notes after paper)
notes down after 3)  Review notes to ensure 3)  Higher level –
therapy session accurate and succinct metacognitive
support
4)  Review-Say-Do

3.  Independence: Office •  Planner 1)  Review therapies 1)  Consistent paths
Room •  Daily 2)  Practice routes so he 2)  Cognitive support
Coming to Gym schedule knows where he is going with phone alarms
therapies on his •  Phone alarm 3)  Set alarms on phone for 3)  Metacognitive
own therapies strategy of pro-active
4)  Practice/role play him prep for day
going to therapy when
alarm sounds

Kim Frey, Oregon, 10/12/18



Thank you!