Development and Implementation of the NRH Aim for Independence Tool. Inbal Eshel, M.A., CCC-SLP Janice Coles, M.S., CCC-SLP

Transcription

1 Development and Implementation of the NRH Aim for Independence Tool Inbal Eshel, M.A., CCC-SLP Janice Coles, M.S., CCC-SLP 1

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3 This is a story of a day treatment program With needs and challenges just like any other aspiring to provide the best possible holistic treatment striving for functional, practical therapy pressed for time seeking a link to family, home, community wanting to be cohesive, but how? 3

4 We decided to create a tool to help us: individualize create realistic, measurable, achievable team long-term goals make these goals concrete and practical enough to get buy-in from patients, family members, and insurance companies as we support each patient in their AIM FOR INDEPENDENCE 4

5 Today we re going to talk about: Context of our Day Treatment Program Development of AIT Structure and Utility of AIT Role of the SLP Case Studies Use of AIT to meet our programmatic needs Thoughts and ideas moving forward 5

6 National Rehabilitation Hospital Network Flagship of Medstar Health, located in Washington, D.C. 1 of 7 hospitals; over 30 offsite locations Specializes in treating persons with physical disabilities caused by: spinal cord and head injuries stroke other neurological and orthopedic conditions Diverse, international population NRH Transitions Neurological Day Treatment Program Primarily treat patients with traumatic brain injury and stroke 6

7 NRH Transitions Neurological Day Treatment Program (Transitions) Purpose: home, community, and social re-integration Clinical team includes: Physician SLP OT PT Social Worker Neuropsychologist Vocational Rehabilitation Specialist as needed Educational Coordinator as needed Case Manager Average Total group census 8-10 LOS: 2 weeks to 5 months Average 6-10 weeks Primarily TBI More R CVA than L CVA 7

8 Home Alone Re-Entry Program Admission Criteria 1 year post-onset: Traumatic brain injury, stroke, brain tumor, anoxia, or other neurological dysfunction > 1 year will be considered on a case by case basis Age 14 or older (younger adolescents meeting all criteria will be considered on a case- by- case basis) Medically stable Reason for referral: Pt currently requires a need for more skilled rehabilitation services through participation in individual and group therapies with a focus toward optimizing capacity for independence in a home setting. Patient must be able/willing to participate in a group-based program Consistent transportation Supportive insurance coverage or self-pay 8

9 Community Re-Entry Program Admission Criteria 1 year post-onset: Traumatic brain injury, stroke, brain tumor, anoxia, or other neurological dysfunction > 1 year will be considered on a case by case basis Age 14 or older ( younger adolescents meeting all criteria will be considered on a case- by- case basis) Medically stable Reason for referral: Pt currently requires a need for more skilled rehabilitation services through participation in individual and group therapies with a focus on community activities such as grocery shopping, managing weekly appointments, accessing transportation options, and other activities outside the home. Patient must be able/willing to participate in a group-based program Consistent transportation Supportive insurance coverage or self-pay 9

10 Historical Program Structure Developed Transitions Neurological Day Treatment Program in the early 90 s Longer lengths of stay acute care and inpatient rehabilitation Developed a model for improving executive functions in this community-based day treatment program One model of care Community and Vocational Focus: All patients went on community outings regardless of impairment severity 10

11 We asked ourselves the question: Are ALL of the patients ready to focus on community re-entry? 11

12 Current Considerations Shorter lengths of stay Severity of impairment Cognitive-communicative skills Physical Skills ADLs Reason for referral Readiness for Community Re-entry/Vocational Services Readiness for Home/ Pre-Vocational Services 12

13 Current Program Structure 2 TRACKS: Home Alone: does not include community outing Community: includes community outing Other possible options: 3 days/week (no PT needs) vs. 5 days/week 13

14 The Aim for Independence Tool (AIT) begins to develop. Developed a framework for both the home alone and community tracks Created 5 TEAM long-term goals that fit within the two tracks Created tiers, or short term goals, within each track 14

15 BREAKDOWN Home Alone Community Independent 1-4 hours 4-8 hours Routine Non-Routine 15

16 How does this work? 1 st Team Conference facilitated by social work/neuropsychology Select track (home alone vs. community) Select tier (1-4 hours, 4-8, etc.) These may change depending on progress Rate patient on functional skill areas Record data on a computerized version of AIT Team identifies potential barriers/problems Team sets LOS 16

17 After the Initial Team Conference With practice, AIT can be used quite efficiently by the team One patient can typically be covered in 5 minutes or less Patients are teamed every two weeks Updated patient information is distributed to each team member weekly 17

18 Role of the SLP The SLP brings a unique perspective, looking at language through the window of cognition and linking performance to functional tasks 18

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20 Home Alone 4-8 Hours - Sample Goals SLP : following a simple schedule OT : Simple cold and hot meal prep PT : Household navigation : Even surfaces such as carpet and negotiating around any environmental obstacle; stair negotiation as needed 20

21 How de we score the functional skill areas? Using a Functional Independence Measure (FIM) - like scoring system (from 0-7). 21

22 Community Tracks Community Independent Routine Non-Routine 22

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24 Community Tracks - Sample Goals Routine Independent SLP Effective communication from a cognitive perspective SLP Planning, organizing, and executing activities OT Moderately-complex billpaying and home finances OT Community errands; complex money transactions PT Navigating familiar community PT Non-dependent transportation; independent navigation in the community Team Self-awareness: able to ID 2-3 areas of impairment and/or incorporate strategies select tasks Team Self-awareness: able to ID strengths and weaknesses and selectively incorporate into compensatory strats I ly 24

25 Self -Awareness Awareness has been found to be linked to attainment of rehabilitation goals and employment outcome (Prigatano & Wong, 1999; Sherer et al., 1998) 25

26 Self -Awareness Patients cannot maintain a productive lifestyle unless they have come to face the realities of their life and this means improving self-awareness and self-acceptance (Prigatano, 1992, p. 60)

27 Crosson et al. (1989): Awareness and Compensation in Postacute Head Injury Rehabilitation 27

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29 Contextual treatment supported by literature Authors recommend contextualized approach to cognitive rehabilitation, with real-world objectives, task-specific training, and intervention in highly functional contexts (e.g., Carlson et al., 2006; Ylvisaker et al., 2003) Ylvisaker et al. (2003) suggest that focusing on cognitive exercises that aim to restore specific cognitive skills in a non-contextual setting has very limited likelihood for generalizability 29

30 Why was this exciting and what did it allow us to do? Individualize Maximizes success and possibilities via concrete, realistic, specific short and long-term goals across multiple disciplines with increased patient/family buy-in Allows for and encourages flexibility within/between tracks Creates increased objectivity and accountability 30

31 Review So far, we ve covered: 1) Context 2) AIT development 3) AIT structure and use 4) Role of the SLP 5) Link to self-awareness and benefits of contextual treatment 31

32 Preliminary Data We have used the tool on a total of 37 patients 7 (19% of total population) entered on Home- Alone track and were discharged on Community track Only 1/37 (3%) had a goal that changed to decrease their independence level 32

33 Trends Patients may start on 1-4 hours track but half of them move to higher-level goals The most common goal = Routine Community Largest number of patients start out with this goal, and even more are discharged at this level Second is Home Alone 4-8 hours Those who start off with a goal of Independent Living tend to leave at that the same goal level; hardly any additional people end up on that tier 33

34 Case Study: Medical History 49-year-old African American female TBI December 2005 Craniotomy for evacuation of a frontotemporal subdural hematoma Returned to work in November 2006; gradual decline May 2008 cognitive/functional decline secondary to encephalopathy Transferred to NRH for inpatient rehabilitation services - August

35 Case Study: Social History Living independently, very successful Hired people to do things for her (clean, cook, etc.) Worked for IBM (sales and services) Living Situation at admission to Day Program: Assisted Living Facility 35

36 Admission: Independent Living Track Observed in group settings, on outings, and in individual sessions As time went on the team realized the severity of her deficits Initiation, motivation, memory, and executive functioning were extremely poor Decreased awareness of deficits Not completing homework assignments Question: Independent Living goal still appropriate? 36

37 Case Study: Admission 37

38 Home Alone: 1-4 Hours Home-Alone 1-4 Hours Worked our way backwards and simplified goals Focused on her being able to complete functional tasks at her assisted living facility 38

39 Case Study: Discharge 39

40 Aim for Independence Tool Pathway Program Dates Long-term Goal Admission September 2008 Community track: Independent Living October 2008 Home alone track: 1-4 hours December 2008 Home alone track: 4-8 hours Discharge February 2009 Community track: Independent Living 40

41 Current Function Discharged from Outpatient Speech August 2009 Participates in NRH Volunteer program Continues to live at the Assisted Living Facility at the independent living level Continues to attend psychotherapy sessions and participate in substance abuse group Community speaker Mentor to the day program 41

42 Feedback from Transitions Team Anonymous survey completed All surveyed team members would recommend the tool to other interdisciplinary clinical teams AIT increases: Efficiency of team meeting Objective tracking of progress/regression/plateau Establishment of common Long Term and Short Term goals across disciplines Structure for patient and family education Creates talking points to identify problems/barriers 42

43 AIT as extension of ASHA FACS ASHA FACS Functional communication perspective Measures and records the functional communication of adults with speech, language, and cognitive communication disorders ( Assesses functional communication in four areas: social communication; communication of basic needs; reading, writing, and number concepts; and daily planning ( AIT Holistic functional disability perspective (ICD*) Incorporates communication and cognition on a continuum, from living at home with supervision to living independently in the community Used by all rehab team members to measure and track functional task performance *International classification of impairments, disabilities, and handicaps, World Health Organization,

44 AIT looking towards the future Expanding the framework to capture pragmatics and self-awareness more explicitly AIT and its functional skill areas can be adapted and validated to meet the needs of different settings/models of care traditional outpatient rehabilitation inpatient rehabilitation pediatric day program adaptation 44

45 As our story comes to a close, the AIT DID help our team individualize create realistic, measurable, achievable team long-term goals make these goals concrete and practical enough to get buy-in from patients, family members, and insurance companies as we support each patient in their AIM FOR INDEPENDENCE 45

46 HEARD WITHIN THE WALLS OF THE TRANSITIONS ROOM

47 Patients say.. Before, I didn t have any desire to do anything. It stimulated lots of desire to want to do things and take more control what to do during the day without someone telling me what to do The program helped me realize what it was to be independent

48 Poem Written by a Former Patient Detained from my progress of living life as I once knew Explained and discussed the options for future living accommodations Attained a new ability to mobilize myself and get around Resolved negative behaviors within myself Persevered to remain steadfast and committed to achieving my goals Accepted accountability for my future Triumphed over obstacles that lie in my way Initiated a new plan for my life Engaged in education to learn new strategies and ways of living Noticed steady improvement in achieving goals assigned to me Transitioned to living a more abundant life!!!! 48

49 Questions? Comments? 49

50 References Carlson P. M., Boudreau, M. L., Davis, J., Johnston, J., Lemsky, C., McColl, M.A., Minnes, P., & Smith, C. (2006). Participate to learn : A promising practice for community ABI rehabilitation. Brain Injury, 20(11), Crosson, B., Barco, P., Velozo, C., Bolesta, M., Cooper, P., Werts, D., & Brobeck, T. (1989). Awareness and Compensation in postacute head injury rehabilitation. Journal of Head Trauma Rehabilitation, 4(3). Frattali, C., Thompson, C., Holland, A., Wohl, C., & Ferketic, M. (1995). The American Speech- Language-Hearing Association Functional Assessment of Communication Skills for Adults (ASHA FACS). Rockville, MD: ASHA. International Classification of Impairments, Disabilities, and Health (2001). Geneva: World Health Organization. Prigatano, G. (1992). Neuropsychological rehabilitation and the problem of altered self-awareness. In: N von Steinbuchel, DY von Cramon, E Poppel, eds. Neuropsychological rehabilitation. Berlin: Springer- Verlag, Prigatano, G., & Wong, J.L. (1999). Cognitive and affective improvement in brain dysfunctional patients who achieve inpatient rehabilitation goals. Archives of Physical and Medical Rehabilitation, 80, Sherer, M., Bergloff, p., Levin, E., High, W., Oden, K., and Nick, T. (1998). Impaired awareness and employment outcome after traumatic brain injury. Journal of Head Trauma Rehabilitation, 13, Toglia, J., & Kirk, U. (2000). Understanding Awareness Deficits Following Brain Injury. NeuroRehabilitation, 15, Wright, J. (2000). The FIM(TM). The Center for Outcome Measurement in Brain Injury. Ylvisaker, M., Hanks, R., & Johnson-Greene, D. (2003). Perspectives on Rehabilitation of Individuals with Cognitive Impairment After Brain Injury: Rationale for Reconsideration of Theoretical Paradigms. Journal of Head Trauma Rehabilitation, 17(3),