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Patient-Centered

Outcomes and the

Coaching Model April 2015

Carrie Childers, Ph.D., CCC-SLP

Kelly Rutherford, MS, CCC-SLP

“What you do with what you have is

more important that what you have.”

- Mark Ylvisaker

Outline

• Patient-centered outcomes

• The Coaching model

• Caregiver training and education

• Class Case Simulations

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Patient-Centered Outcomes

What are Patient-

Centered Outcomes?

Patient-Centered Outcomes

Clinician Determined

Goals

• Patient/family with

limited goal awareness

• Little awareness of how

treatment will be

relevant to life needs

• Reduced likelihood of

real-life rehearsal that

may yield carry-over of

skills

Collaborative Patient-

Centered Goals

• ↑ motivation with

therapeutic process

• Improved self-awareness

• Improved meta-

cognitive strategy

• Quicker rates of

generalization Tippett (2012); Kennedy, et al. (2012)

Patient-Centered Outcomes

Intentions for PCOs and

Actuality of use…

• Maitra (2006): younger,

acutely ill patients reported

more collaboration with

healthcare professionals

• Complex medical

complications are at risk

factor for higher rates of

vulnerability and reduction

in decision making

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Patient Centered Outcomes

WHO Framework

Prior to 2001

Impairment-based Treatment

Approaches

WHO

2001 → Present

Activity/Participation Treatment Approach

World Health Organization (2001)

• focus shift changed how we

look at the medical model…

• Assessment and Intervention

are now truly comprehensive

and dynamic…

• Quantitative and Qualitative

information combined yield

more informed goal

determination…

Is there more to it?

Patient-Centered Outcomes

Practice Shifts and

Advancement

• Goals established are no

longer strictly criterion

based

• Goals now must

correlate with life

competence

The goal should always be

to improve someone’s

Quality of Life!

Patient-Centered Outcomes

• What’s the next step?

– Contextual factors

• Setting

• Need

• Desire

– Maintenance of client values while collaboratively

bridging that gap

• Where they are versus where they want to be…

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Patient-Centered Outcomes

Strict use of standardized

measures is a

decontextualized

approach…

• Translation into

dynamic intervention

plan

• Consideration of

personal value/desire

Patient-Centered Outcomes

Equal consideration of quantitative and qualitative

measures provides the most information…

• This easily translates into a dynamic intervention plan

• Easily allows for collaboration of personal/familial

values and desires

• Maintains professional capacity for measurement,

documentation, and insuring generalization of skills

Patient-Centered Outcomes

Quantitative Patient-

Centered Outcomes

• # of social activities

attended

• Grades

• Survey completion

throughout the course of

intervention

• # of communicative

successes for a

particular setting

Qualitative Patient-

Centered Outcomes

• Self-report of successes

• Personal satisfaction

with a particular

outcome

• Report of sense of

wellbeing

Kennedy, et al. (2012)

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Patient-Centered Outcomes

A combination of Quantitative and

Qualitative outcomes is optimal

Patient-Centered Outcomes

Examples of combined quantitative and qualitative goal writing:

• The client will… – Respond to spoken yes/no questions via head nods and/or

yes and no verbalizations with at least 80% accuracy in

structured conversations on topics of personal relevance.

– Silently read newspaper articles and respond to written

comprehension questions about them with 80% accuracy.

– Initiate a verbal comment or questions in aphasia group at

least once per session.

– Order dinner at a restaurant with less than two prompts

from his spouse via self/family report.

Patient-Centered

Outcomes

• Modalities should be linked to

patient activity/ participation

preferences

• Integrity of documentation is

maintained through

measurement

• Documentation can be

improved as qualitative

measures support generalization

of skills

Goal

Considerations

for Outcome

Determination…

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Patient-Centered Outcomes

• Evidence-Based Practice:

Integration of research principles and clinical

experience with principles of Patient-Centered

Outcomes

http://www.asha.org/

Patient-Centered Outcomes

Individualized Intervention Plan

Research

Experience

Patient Values

Integration of Principles

• EBP framework lends

itself to be tailored to a

specific patient

– Consideration of patient

autonomy

Patient-Centered Outcomes

Potential barriers to implementing PCOs:

• Institutional barriers

– Type of institution (i.e. acute care versus day

program)

• Procedural barriers

– High productivity demands

• Complicating patient factors

– Cognitive impairment Womack (2012)

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Patient-Centered Outcomes

Relevant Populations:

• Any individual and their

families who are

navigating the

habilitation/

rehabilitation process

• Our focus today will be

based around case

studies…

– Adolescent TBI survivor

– Adult CVA survivor

Patient-Centered Outcomes

TBI Survivor

• Considerations for life

competence and

success…

– Daily needs

– Social activities

– Educational needs

– Future goals

CVA Survivor

• Considerations for life

competence and

success…

– Daily needs

– Social activities

– Vocational needs

– Future goals

Patient-Centered Outcomes

Dynamic Assessment

Multi-modal Intervention

Positive Clinician→

Client Interaction

Client Motivation

Generalization

True

Collaboration

Benefits to beginning

tx in this format are

many…

Further benefit can be

Seen in:

• Increased likelihood

for reaching out for

emotional support

• Requesting guidance

for decision making.

Patient-Centered Outcomes

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Patient-Centered Outcomes

• Other considerations when determining

development of PCOs…

– An individuals ability to participate in life

situations

– The environment(s) in which they use

communication and cognitive skills

– An individuals attitudes and feelings regarding

themselves

– Their individual limitations

• The Coaching model helps us bridge

the gap between the therapeutic

process and PCOs…

• It naturally helps to alleviate patient

anxiety associated with goal

achievement…

• It helps SLPs promote patient/family

adherence to therapeutic plans…

• It helps SLPs foster improved

motivation in our clients…

PCOs

and the

Coaching

Model…

Patient-Centered Outcomes

Patient-centered Outcomes

Finding what works for each individual…

www.careerrocketeer.com

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The Dynamic Coaching

Model “Value is in the process, not just the

product.” Kennedy, Krause, O’Brien, & Yu 2011

Why Dynamic Coaching?

Collaboration

Ownership

Evidence-based

Practice

Generalization

Collaboration

• The clinician and client are partners in

– Determining goals

– Identifying successful strategies

– Evaluating outcomes

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Ownership

• The client guides session content and focus

– Takes responsibility for selecting, implementing,

and evaluating novel strategies

• Problem solving and critical thinking

Generalization • Everyday activities

• Self-selected strategies

– tested in authentic environments

• Clients develop self-regulation skills and

become experts in implementing strategies to

meet their current and future needs. (Kennedy et al.,

2011)

Evidence Base • Best practices in cognitive rehabilitation therapy

(CRT) (www.ancds.org)

– Functional, self-identified goals from functional

assessment

– Direct instructional practices that capitalize on

procedural, implicit memory

– Practice scheduling should be distributed (Ehlhardt et al., 2008; Kennedy et al., 2008; Sohlberg et al., 2003; Sohlberg et al., 2007; Turkstra et al., 2003)

11/18/2011 Kennedy & colleagues)

– Practice of authentic tasks to automaticity (Bruning, Schraw, & Norby,

2011)

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Evidence Base

• Aligns with recommendations for best

practice from ASHA (www.asha.org/Practice-Portal/Clinical-Topics)

– ↑ education for clients and family members

– External supports and strategies

– Development of client-centered goals

Coaching Process

Assessment & Interview

Treatment & Support

Outcomes

Coaching Process

Assessment & Interview

Treatment & Support

Outcomes

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Assessment & Interview

• Observation

• Interviews/Questionnaires

– Patient history & current status

– Personal communication goals

– Description of current strategies*

• Norm-referenced assessment

• Criterion-referenced assessment

• Self-Regulation Skills Inventory – Main area of difficulty, awareness of deficit,

motivation to change, strategy awareness, strategy

use, strategy effectiveness

• Self-Awareness Deficit Interview (SADI) – Deficits, functional impact, realistic goals?

– www.me.umn.edu/.../self-aware/

• Patient Competency Rating Scale (PCRS) – Patient and family rating of basic skills

– tbims.org/combi/pcrs/

Self-Awareness Measures

• Discuss evaluation results with client – in

terms of functional performance – Develop individualized recommendations

• Develop objectives based on the client’s goals

and current strategies – Backward Design (Markle, 1967)

• Provide overview for future sessions

SLP Role Post Assessment (Kennedy & Krause, 2010)

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Coaching Process

Assessment & Interview

Treatment & Support

Outcomes

Areas of Treatment

Self- Advocacy

Self- Management

Self-Learning

Self-Learning

What is it I want to learn or relearn how to do?

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Self-Learning Goals

• Strategy-based:

–

• Performance-based:

–

• Process-based:

–

Self-Learning Strategies

• Vary by individual and learning profile

• Traumatic Brain Injury

–

• Stroke

–

• Degenerative Disorder (e.g., ALS)

–

Examples

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Tracking Strategy Use

Strategy Care Help Use Effort Worth

How much do

I care about

this strategy?

How helpful

was this

strategy?

How

often did I

use it?

How much effort

did it take to use this

strategy, or how

hard was it to use

this strategy?

Was it worth

it?

Rate all responses as 1-5: (1) Not at all, (2) a little, (3) somewhat, (4) quite a bit, (5) very/all the time

Self-Management

How can I manage my life effectively?

Self-Management Goals

• Time management: –

• Organization: –

• Planning: –

• Prioritizing: –

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Self-Management Strategies

• Time management:

–

• Organization:

–

• Planning:

–

• Prioritizing:

–

Examples Plan Do Review

Plan Do Review

Task to be

completed

Estimated

time to

complete

Actual time to

complete

How accurate was the

estimate? What took

more/less time?

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Self-Advocacy

Do I know how to speak up on my behalf and

ask for what I need? (CanLearn Society, 2013)

Self-Advocacy Goals (CanLearn Society, 2013)

• Know yourself

• Know what supports you need to be successful

• Know how to communicate your needs

effectively

Self-advocacy Strategies

• Knowing yourself

–

• Knowing what supports you need

–

• Knowing how to communicate with others

–

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Dynamic Coaching Example-

Brooke

Background Information

• University senior in the general education

program

• TBI sophomore year of high school following

a motor vehicle accident

• 3 weeks in a coma

• Speech, OT, and PT = 2 months inpatient, 6

months outpatient following accident

• Gross and fine motor intact

Assessment Results

• Cognition

– Attention: WNL

– Memory: moderate deficits in delayed recall

– Organization: mild deficits

– Planning: WNL

– Judgment/problem-solving: WNL

• Expressive language: mild word-finding deficits

• Receptive language: WNL

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Interview

• Strategies

– Reads assignments multiple times

– Goes to class

• Chief complaints

– Does poorly on tests because she can’t remember

studied information

– Has difficulty determining the priorities of tasks

and finishing them on time

– Has difficulty identifying and asking for effective

accommodations.

Initial Sessions (~1-3)

• Overview coaching structure

• Establish Initial goals

• Evaluate current strategies

• Introduce 1-2 strategies

• Determine carryover assignments

Overview Coaching Structure

• General structure and expectations

• Portfolio

• Example Table of Contents

– Exam strategies

– Time-management strategies

– Prioritizing strategies

– Word-finding strategies

– Resources

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Establish Initial Goals

• Brooke wants to maintain a B-average on tests in all

of her classes over the course of the semester

– Brooke will use learning strategies (e.g., imagery,

guided questioning) to correctly answer 60% of

questions presented after she reads a class assignment.

• Brooke wants to respond to class questions using

complete utterances

– Brooke will use word-finding strategies (e.g.,

circumlocution) to answer 50% of class questions

using complete utterances.

• .

Establish Initial Goals

• Brooke wants to receive academic effective

accommodations

– Brooke will advocate for necessary academic

accommodations by presenting relevant information to

familiar and unfamiliar listeners orally or in writing

during authentic situations in 80% of opportunities.

Evaluate Current Strategies

• Reflect on what works

– Why?

• Reflect on what doesn’t work

– Why?

• Identify barriers?

– Environmental

– Personal

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Introduce New Strategies

• Problem-solving

– Identify problem

– Develop hypothesis

– Test hypothesis

– Evaluate results

• Plan-do-review

• Remember: The goal of any new learning is

automaticity (Bruning, Schraw, & Norby, 2011)

The Modeling Process

Discuss Rationale

Model task

Model task steps

Have client

practice task steps with

guidance

Have client

practice task with guidance

Have client complete the

task independently

Carryover Assignments

• Complete Plan-do-review chart for one week

• Write down one specific problem to address in

the next session

• Purchase/bring a planner

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Ongoing Sessions

• Evaluate current strategies

– Use real life examples

• Discuss emergent problems

– Use problem-solving to select best strategy

• Introduce/Review 1-2 new strategies

– Apply using real life materials

• Determine carryover assignments

– Use real life activities

Coaching Process

Assessment & Interview

Treatment & Support

Outcomes

Discharge

• Procedural Knowledge: Client independently

implements strategies to meet established

goals

• Conditional Knowledge: Client knows where,

when, and why to implement strategies to

novel situations

• Advocacy: Client feels confident asking for

effective accommodations/supports.

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Keep In Mind

• Process not product

• Cautious technology implementation

• Reliance on multiple outcomes

– Actual behavior vs. self-report

• Explicit description of cost/benefit

– Time vs. strategy

Keep In Mind

• Prochaska’s stages of change

– Precontemplation

– Contemplation

– Preparation

– Action

– Maintenance

– Strategy/routine

Group Cases

John Smith Miles Standish

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Resources

• Self-Awareness Deficit Interview (SADI)

– Search “self-awareness deficit interview” online

for download

• Patient Competency Rating Scale (PCRS)

– tbims.org/combi/pcrs/

• Self-advocacy handout from CanLearn Society

– Search “self-advocacy CanLearn Society” online

for download

• Practice guideline publications on cognitive

rehabilitation therapy for persons with TBI

– www.ancds.org

References

• Evidence-Based Practice. Accessed on March 27, 2015. American Speech-Language-Hearing Association. Retrieved

from http://www.asha.org/Members/ebp/default/#_ga=1.137295984.1132345120.1427211119

• Helm-Estabrooks,N., Albert, M.L., Nicholas, M. (2014). Manual of aphasia and aphasia therapy (3rd ed). Austin, TX:

Pro-ed.

• Kagan, A., Simmons-Mackie, N., Rowland, A., Huijbregts, M., Shumway, E., McEwen, S., . . . Sharp, S. (2008).

Counting what counts: A framework for capturing real-life outcomes of aphasia intervention. Aphasiology, 22(3),

258–280.

• Kennedy, M.R.T., Obrien, K.H., Krause, M.O. 2012, December. Bridging person-Centered Outcomes and Therapeutic

Processes for College Students with Traumatic Brain Injury. SIG 2 Perspectives on Neurophysiology and Neurogenic

Speech and Language Disorders. Vol 22, 143-151. American Speech-Language-Hearing Association.

• Maitra, K. K., & Erway, F. (2006). Perceptions of client-centered practice in occupational therapists and their clients.

American Journal of Occupational Therapy, 60(3), 298–310.

• Tippett, D.C. 2012, January. Current Concepts in Treatment Planning: patient Centered and Evidence-Based Practice

in Speech-Language Pathology. SIG 15 perspectives on Gerontology. Vol 17, 27-33. American Speech-Language-

Hearing Association.

• Womack, J.L., 2012, April. The Relationship Between Client-Centered Goal-Setting and Treatment Outcomes. SIG 2

Perspectives on Neurophysiology and Neurogenic Speech and Language Disorders. Vol 22, 28-35. American Speech-

Language-Hearing Association.

• World Health Organization. (2001). ICF: International Classification of Functioning, Disability and Health – report.

Geneva, Switzerland: Author.

References

• Bruning R.H., Schraw, G.J., & Norby, M.M. (2011). Cognitive psychology and instruction (5th ed.). Boston, MA:

Pearson.

• CanLearn Society (2013). Self-Advocacy. Retrieved from: http://canlearnsociety.ca/

• Ehlhardt, L. A., Sohlberg, M. M., Kennedy, M., Coelho, C., Ylvisaker, M., Turkstra, L., & Yorkston, K. (2008).

Evidence-based practice guidelines for instructing individuals with neurogenic memory impairments: what have we

learned in the past 20 years?. Neuropsychological rehabilitation, 18(3), 300-342.

• Kennedy, M.R.T & Krause, M.O. (2010). Return-to-college issues for students with traumatic brain injury [PowerPoint

slides]. Retrieved from

http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CB8QFjAA&url=http%3A%2F%2Fbl

og.lib.umn.edu%2Fgara0030%2Figgds%2FKennedy_Krause.pdf&ei=I7MeVbj5KIyNyASC5YKoBg&usg=AFQjCNH

TZyXYb65dzIjjVAaV8_JorgQxiA&bvm=bv.89947451,d.aWw

• Kennedy, M.R.T., Krause, M.O., O’Brien, K., & Yu, J. (2011). Coaching college students with brain injury: A dynamic

intervention approach [PowerPoint slides]. Retrieved from:

http://www.asha.org/events/convention/handouts/2011/kennedy-krause-obrien-

yu/#_ga=1.125653194.1130611747.1424870829

• Kennedy, M. R., Krause, M. O., & Turkstra, L. S. (2008). An electronic survey about college experiences after

traumatic brain injury. NeuroRehabilitation, 23(6), 511-520.

• Markle, D. G. (1967). On the control of runaway programers. NSPI Journal, 6(7), 16-20.

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References

• Ownsworth, T. L., McFarland, K., & Young, R. M. (2000). Development and standardization of the self-regulation

skills interview (SRSI): A new clinical assessment tool for acquired brain injury. The Clinical Neuropsychologist,

14(1), 76-92.

• Sohlberg, M. M., Avery, J., Kennedy, M., Ylvisaker, M., Coelho, C., Turkstra, L., & Yorkston, K. (2003). Practice

guidelines for direct attention training. Journal of Medical Speech Language Pathology, 11(3), xix-xix.

• Sohlberg, M. M., Kennedy, M., Avery, J., Coelho, C., Turkstra, L., Ylvisaker, M., & Yorkston, K. (2007). Evidence-

based practice for the use of external aids as a memory compensation technique. Journal of Medical Speech Language

Pathology, 15(1), xv.

• Turkstra, L. S., Holland, A. L., & Bays, G. A. (2003). The neuroscience of recovery and rehabilitation: What have we

learned from animal research?. Archives of Physical Medicine and Rehabilitation, 84(4), 604-612.