becky khayum, m.s., ccc-slp president, memorycare corporation ·

Pathways to Reimbursable LPAA: Developing & Using Goals in a Changing Reimbursement Environment

Becky Khayum, M.S., CCC-SLPPresident, MemoryCare Corporation

Presented to Aphasia Access

Saturday March 18, 20173:00-4:00pm

Orlando, Florida

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Disclosures: B. Khayum, M.S., CCC-SLP

Relevant Financial Relationships§ Owner of a for-profit company, MemoryCare

Corporation, which provides therapy services to people with dementia, including aphasic dementias. (2010 - present)

§ Consultant for Communication Bridge research study at the Cognitive Neurology and Alzheimer's Disease Center at the Northwestern Feinberg School of Medicine and receives reimbursement for consultation time and treatment sessions for individuals with PPA. (2013 - present)

§ Received reduced registration fee from Aphasia Access

Session Objective:Implementation of Reimbursable LPAA Interventions

§ University faculty or clinical supervisors§ How to train students to apply the LPAA in the various

healthcare settings§ Preparing students for the realities they will face: productivity

expectations; clinicians around them simply “pulling out the workbooks”

§ Community Aphasia Centers§ Treatment interventions and goals that may be applicable for

your center participants§ Providers in healthcare settings

§ Concrete ideas for implementing reimbursable LPAA interventions in your setting

3 Copyrighted Materal: Do not copy or distribute.

ASHA Leader Article:“Are Life Participation Goals Reimbursable?”

October 2015 http://leader.pubs.asha.org/article.aspx?articleid=2449240

By Janet Brown & Candace Vickers

“Traditional treatment in medical settings focuses on addressing impairments and setting goals that could be quantified, but they do

not necessarily have a direct connection to life outside the treatment room. The ICF framework validates the focus of rehabilitation to

include all aspects of life so people can participate in life as fully as possible. “Patient-centered care” or “person-centered care” are other frequently used phrases that signal the change in treatment

focus from isolated impairments to overall change in life participation. By using this framework to conceptualize goals, clinicians can individualize treatment to each patient’s unique

needs and circumstances. ”

4 Proprietary and Confidential

Barriers to providing LPAA Interventions

§ Treating all evaluations as diagnostic§ Many SLP’s are focusing upon the sole use of

traditional standardized tests for their assessments, resulting in identification of the impairment, but failing to assess the impairment’s impact on life participation in desired activities

§ Resulting plan of care and goals are focused at the impairment level only and often aren’t focused on functional outcomes


Barriers to Providing LPAA Interventions

§ Productivity Requirements§ SLP’s are pressured to provide quantity over quality in

many treatment settings§ Temptation to “grab a workbook” or generic “brain

game” on the iPad for treatment sessions§ Incorporating family members into plan of care can be

difficult (phone call to a family member is considered “unbillable time”)

§ Creation of personalized communication aids are difficult to create, print, and distribute


Some potential solutions….

§ Training SLP’s to administer person-centered evaluations that are client-directed rather than clinician-directed§ Use of patient-reported outcome measures§ Formulation of functional, person-centered long term and short

term goals

§ Training SLP’s on strategies to maintain productivity expectations while providing LPAA interventions, in addition to involving family members and using technology to create person-centered aids within treatment sessions


Conducting a Person-Centered Assessment

Flipping the Rehab Model (M. Bourgeois, 2015)§ Put the client and family members at the center of the evaluation § Start off by building rapport and identifying their concerns§ Determine underlying impairments that are causing their concerns§ Determine how impairments are limiting life participation§ Administer standardized tests or subtests of standardized tests to further

assess areas concern § (e.g., Difficulty conversing over the telephone – administer subtest

of CADL-2 or ALFA; Difficulty with comprehending conversations in group settings – administer Auditory Comprehension subtest of the WAB)

§ All goals are then written to address their concerns and are focused upon use of personally relevant stimuli to address functional outcomes

Copyrighted Materal: Do not copy or distribute.

6 Steps for a Person-Centered Assessment

§ BUILD RAPPORT: WHO IS YOUR CLIENT AS A PERSON?

§ OBSERVE COMMUNICATION/ENVIRONMENT

§ INTERVIEW: ASK YOUR CLIENT/FAMILY MEMBERS ABOUT THEIR CONCERNS/FRUSTRATIONS

§ DETERMINE IMPACT ON LIFE PARTICIPATION IN DAILY ACTIVITIES

§ EDUCATE AND COUNSEL

§ ADMINSTER STANDARDIZED ASSESSMENT


Standardized Assessment Considerations

§ Activity-based assessments§ CADL-2, Communication Activities of Daily Living§ ALFA, Assessment of Language-Related Functional

Activities§ Patient-reported outcome measures

§ ALA, Assessment for Living with Aphasia § CETI, Quality of Communication Life Scale§ ASHA QCL, Quality of Communication Life Scale


Goal Writing

§ Alwaysincludetheindividual’sandfamily’sinput§ Goalsshouldbeindividualizedandshouldfocusonfunctionaloutcomes

§ Goalsshouldberealistic;mayneedadjustthelevelofcueing

§ KeyComponents:§ Evidence-basedinterventionbeingtargeted§ Targetlevelandmodesofcueing§ Targetaccuracy§ Functionalactivitytargeted

§ Baselinesneedtobetakenforeachgoal,tobelistedalongwithaccuracyatdischarge


Sample Goals


§ PWA will demonstrate use of semantic circumlocution during structured conversation regarding their recent vacation to retrieve word or communicate message with 90%, given minimal verbal cues, to increase functional communication with family and friends.

§ PWA will utilize semantic circumlocution and phonemic self-cueing strategies to increase lexical retrieval of personally relevant names to 80% accuracy in home rehearsal program, given minimal verbal cues, to increase functional communication with family and friends.

§ PWA will state Steak ‘n Shake Drive Thru order during script training task, with goal of <15 seconds to state script content and < 3 errors, given minimal written and verbal cues, to increase ability to independently order meal at drive-thru.

§ PWA will independently describe his condition of aphasia to a stranger in <20 seconds and with < 2 errors during oral reading from written script, to increase ability to converse and communicate needs with strangers in the community.

§ PWA will demonstrate comprehension of 4/5 choice questions regarding desired daily activities with use of picture cues in a communication book, given moderate verbal/gestural cues, to increase ability to comprehend and make choices during daily conversations with spouse and family members.

Considerations for Neurodegenerative Diseases

§ Primary Progressive Aphasia§ Aphasia as a result of other dementia syndromes (e.g., Alzheimer’s dementia,

behavior variant of Frontotemporal Dementia)

§ Considerations:§ Traditional standardized assessments likely won’t capture

functional gains § Need to consider strategies for current communication needs, in

addition to anticipating communication needs as disease progresses

§ Interventions/strategies need to be modified over times§ Write realistic goals, increasing cueing where necessary


How to use Technology While Complying withProductivity Expectations

1. Determine if you can take company tablet/laptop or your personal device into your treatment sessions

2. Establish Wi-Fi for your sessions3. Create personalized aids DURING your treatment

sessions, with input from your client and family4. Have family members email pictures to you if they can’t

be present5. After session: PRINT in rehab office6. Ask your manager to buy laminator ($40 at Target)7. Run your materials through the laminator8. Cut and organize memory/communication wallets

DURING your next treatment session

Copyrighted Material: DO NOT REPRODUCE.

How to Involve Family Members

§ Encourage family members to be a part of your sessions: this is a team approach!

§ If they can’t be physically present at the treatment sessions:§ Call them via phone or Skype/Facetime for a few minutes

during your session§ Leave a Memory Book information form (see Bourgeois

form) and other information-gathering forms for them to complete outside of the session

§ Email them with all recommendations and updates with your client at the end of the session. Review main points.

§ Ask them to email any pictures that may be helpful for your aids


Creation of PERSONALIZED Home Exercise ProgramsUsing Technology

§ Computer/tablet-based home exercise programs§ Use of computer or tablet to create paper-based

home exercise programs§ **Why recommend generic brain game apps or

worksheets for homework when you can easily create a program that is personalized and will likely have increased carry-over to daily activities?


Goal of LPAA Interventions

Focusing on both impairment-based and activity/participation-based interventions, with a focus on use of personalized stimuli and with the

over-arching goal of increasing functional communication and increased life participation


Expressive Aphasia: Daily Conversations

§ Evidence-based Interventions:§ Semantic Circumlocution or Phonemic Self-Cueing§ Personally Relevant Word Rehearsal programs targeting

lexical retrieval/motor speech production§ Script training§ Word/Picture-based Communication Aids§ Electronic Communication Aids

§ Client/family member complaints:§ “I know what I want to say, but I can’t pull out the word.”§ “We are constantly playing 20 questions… he can’t

remember the names of people and places.”§ “He becomes upset when he can’t tell me what he wants.”


Lexical Retrieval/Motor Speech Production

§ Rehearsal of personally relevant words§ Home program designed to increased the individual’s lexical retrieval

and/or motor speech production of words that they frequently use during daily conversation


Lexical Retrieval: Personally Relevant Word Flashcards


Lexical Retrieval:Personally Relevant Word Writing Practice


Script Training


Formulate and type up scripts during treatment sessions. Assign as a home exercise program.

Script Visual Aid

QUESTIONS FOR LANDSCAPERS:

§ The sidewalk is sinking. How can we repair the sidewalk?§ We are considering paver bricks for our sidewalk coming up to the house. Can

we get an estimate on this?§ What would it cost to rip out the front yard and re-landscape the grass?§ We would like to pull out the burning bush.§ We would like to put a row of bushes along the north side of the yard as a screen

between the two properties. How much would this cost?§ The tree out front – are the roots sticking out too much? Is there a way to put soil

and grass on top of these?§ How much will it cost to put the side drain underground?§ Can the driveway be leveled?§ Can the garage floor be resurfaced?§ Are you responsible if you hit a telephone or cable line?


Script Visual Aid

No rehearsal. PWA reads off

script at dinner and is able to say prayer much more fluently.


Use of Smart Phone/Tablet Pictures

§ Use of Smart Phone/Tablet Pictures§ Develop system of taking pictures during daily activities;

integrate pictures into daily conversations

Pictures from photo stream Story Creator AppCopyrighted Materal: Do not copy or distribute.

Communication Wallet

§ Portable word- or picture-based aid to facilitate daily conversations

§ Helpful apps: § Microsoft PowerPoint


Communication Wallet


Graphic Cueing Aid: Personalized Grocery List


Communication Boards/Books

§ Word or picture-based aids to facilitate daily conversations in the home§ Helpful Apps: Pic Collage


© MemoryCare Corporation. These materials are not to be reproduced or distributed without prior written consent.

Memory Book: Visual Supports

Creative Arts Discussions History Discussions

Receptive Aphasia: Daily Conversations

§ Evidence-based Interventions:§ Positive communication strategies: care partner/staff

training§ Environmental modification§ Written cues§ Word or Picture-based Communication Aids

§ Client/family member complaints:§ “I think she is having problems with her hearing.”§ “I have trouble understanding people when they talk quickly or

have accents… following movie plots is more difficult for me.”§ “She can’t follow multi-step directions anymore.”§ “I don’t feel like she understands what I’m trying to tell her. I

don’t know how to get through to her.”


Receptive Language

Facilitating auditory comprehension: § Training communication partners to

use the following strategies: § eliminating distractions§ simplifying sentence structure§ slowing rate§ increasing use of nonverbal cues§ use of written or picture cues


Receptive Language: Written cues

Copyrighted Material: DO NOT REPRODUCE.


Receptive Language: Picture cues


Telephone Conversations

§ Evidence-based Interventions:§ Script Training§ Word-based communication aids

§ Client/family member complaints:§ “I have trouble making phone calls… particularly

with strangers… like ordering take out or scheduling a haircut.”


John, I am going to: PUBLIXWHOLE FOODSCVSLIBRARYDOG PARK

John, when are you coming home?

John, I want to pick Fluffy up. What time should I come?

Betty, do we have a match…. TOMORROWMONDAYWEDNESDAYFRIDAY

What time? ____________

Sue, where are we going for dinner?What time?___________


Number Strategies

§ Use of written aids to facilitate reading/writing of phone numbers and addresses or taking phone messages

§ Written aid for TV/radio stations

§ Templates for check-writing

§ Tip calculator apps Copyrighted Materal: Do not copy or distribute.

SpecialthankstotheresearchparticipantsandtheirfamilymembersintheCommunicationBridgeStudyfortheirtime

andcommitmenttoresearch,withoutthemnoneofthisworkwouldbepossible.Picturesandgraphicsinthispresentation

createdbyparticipantsinvolvedinthisresearch.

Formoreinformationpleasecontact:[email protected] | [email protected]

NS075075;DC008552;AG13854

Acknowledgements

Questions & Discussion


becky khayum, m.s., ccc-slp president, memorycare corporation ·

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