Setting Treatment Goals in Rehab Settings In an ASHA online chat, experts Kimberly Eichhorn and Christine Matthews discussed restorative and compensatory treatment strategies. The Leader listened in. Overheard
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Overheard  |   December 01, 2016
Setting Treatment Goals in Rehab Settings
Author Notes
  • Kimberly Eichhorn, MS, CCC-SLP, is a clinician and assistive technology professional at the VA Pittsburgh Healthcare System and field faculty for the School of Health and Rehabilitation Sciences at the University of Pittsburgh. She is an affiliate of ASHA Special Interest Group 12, Augmentative and Alternative Communication. Kimberly.Eichhorn@va.gov
    Kimberly Eichhorn, MS, CCC-SLP, is a clinician and assistive technology professional at the VA Pittsburgh Healthcare System and field faculty for the School of Health and Rehabilitation Sciences at the University of Pittsburgh. She is an affiliate of ASHA Special Interest Group 12, Augmentative and Alternative Communication. Kimberly.Eichhorn@va.gov×
  • Christine Matthews, CScD, CCC-SLP, BCS-S, is the speech pathology program supervisor at the VA Pittsburgh Healthcare System, practicing primarily in dysphagia management, and an adjunct assistant professor in the Department of Communication Science and Disorders at the University of Pittsburgh. She is an affiliate of ASHA Special Interest Group 13, Swallowing and Swallowing Disorders (Dysphagia). Christine.Matthews@va.gov
    Christine Matthews, CScD, CCC-SLP, BCS-S, is the speech pathology program supervisor at the VA Pittsburgh Healthcare System, practicing primarily in dysphagia management, and an adjunct assistant professor in the Department of Communication Science and Disorders at the University of Pittsburgh. She is an affiliate of ASHA Special Interest Group 13, Swallowing and Swallowing Disorders (Dysphagia). Christine.Matthews@va.gov×
Article Information
ASHA News & Member Stories / Overheard
Overheard   |   December 01, 2016
Setting Treatment Goals in Rehab Settings
The ASHA Leader, December 2016, Vol. 21, online only. doi:10.1044/leader.OV.21122016.np
The ASHA Leader, December 2016, Vol. 21, online only. doi:10.1044/leader.OV.21122016.np
Participant: How do you balance between restorative and compensatory strategies, particularly in outpatient and home care settings?
Kimberly Eichhorn: Personally, I always try to broach some of each, depending on patient abilities. For example, if a patient with aphasia has no means for functional communication, I am going to immediately attempt to provide some compensatory or alternative way for them to communicate needs to caregivers/family. However, I also will begin assessment and treatment attempting to restore verbal communication.
Christine Matthews: I think of compensatory as key in the beginning (i.e., when the communication or swallowing impairment first hits) to get them to an OK place, and then focus on restorative while never losing the benefit of compensatory strategies. Home care settings may lend themselves more to compensatory, but that’s not always the case. You need a certain treatment frequency for it to be restorative in nature.
Participant: How do you manage clients and family members who are unrealistic with regard to expectations for treatment outcomes?
Matthews: Education, setting specific measureable goals, demonstrating progress or lack thereof, and providing options for compensation are key to turning unrealistic expectations into eye-opening experiences. I always communicate to my patients and their families that a treatment plan is not set in stone—that we develop goals and tasks with the possibility that modifications will be needed, and that this is OK and a good thing.
Eichhorn: Keeping an open dialogue regarding progress toward goals and/or recommendations for modifications can be helpful in coming to reasonable goals.
Participant: Any recommendations for incorporating technology into therapy sessions and home programs?
Eichhorn: Let’s first clarify that we can consider all levels of technology, low to high, and they should be considered as complementary—not a replacement for verbal communication in all cases. I often incorporate the use of apps on tablets for feedback or home programs. Do you have a specific patient population in mind?
Participant: More for cognition and language in the outpatient setting.
Eichhorn: I often use apps like Notability, Inspiration Maps and CanPlan as part of my work with cognitive rehabilitation. This goes hand in hand with that balance of compensatory and restorative discussion though—anytime I am using technology, I am usually working on underlying strategies/skills as well, that I am hoping will generalize to other novel situations. Use of technologies is supportive. As for language, this is a bit trickier in my opinion. I find that I often use tech as a part of my restorative treatment sessions as well. I have not found many pre-fab apps that allow for customization regarding individual patient needs/treatment stimuli and/or right/wrong feedback. I usually make my own treatment materials and put it on some other [customizable] app, like educational flashcards.
Matthews: We have a group of SLPs at the VA who are developing a platform for delivering known treatment approaches (e.g., SFA [semantic feature analysis], TUFs [treatment of underlying forms]) using technology so the patients can get feedback from either the clinician or the app. The key to using apps is that the patients get more than right/wrong feedback, including cues and second chances.
Participant: Using time in sessions to develop a patient relationship and set goals is so important, but how can you justify it to other therapists who see it as nontherapeutic? How should you document this time as billable?
Eichhorn: Developing rapport with your patient can happen during evaluation, treatment and education activities, all of which are billable procedures. Establishing a relationship, building trust, and setting goals are not at all “nontherapeutic” and are essential to maintaining a good relationship with your patient. Again, you wouldn’t want to spend the majority of your sessions doing this, but at least a small part of every session should include some aspect of this. If you spend just five minutes of a 50-minute session building rapport, you have the other 90 percent of your session for “billable” procedures. Initially, you will spend more time than that, particularly with goal setting, but providing education during this process can also make this aspect of your care a billable procedure.

Developing rapport with your patient can happen during evaluation, treatment and education activities, all of which are billable procedures.

Participant: With severe Wernicke’s aphasia, what is your general treatment approach? I mostly read that context-based interventions are key, but have you had success with or learned of any restorative interventions that you’ve found effective with this population?
Matthews: I focus on input and output buffers with these patients. Working on attention, working memory and span. Repetition is also really important, as is teaching these patients how to pick up on stress/pattern cues during conversations.
Eichhorn: So, think about input/output span and increasing the length of units of information (sound level or semantic) that they can hold on to.
Participant: Do you have a framework for interviewing to gather information from patients and families?
Eichhorn: I’d like to think that we, as specialists in communication, all do a good job at asking questions. Sometimes I find myself talking too much, though! In general, it is always a good idea to start with open-ended questions and tailor additional questions or question format based on initial responses. Rapport can be built better when patients/family feel heard first rather than interrogated with clinicians providing summary, reflection or clarification statements. Some techniques and principles from motivational interviewing—often used by our colleagues in psychology—can be highly effective in gleaning information, developing rapport and establishing appropriate goals.

Rapport can be built better when patients/family feel heard first rather than interrogated with clinicians providing summary, reflection or clarification statements.

Participant: How do we help therapists who have been in the game a long time to break the habit of doing things that are static in acute rehab? Like APT [attention process training], worksheets, etc. I am not sure they focus on personal patient/caregiver goals and, at times, it seems as if they have therapy tasks they do with each patient, regardless of interests or lifestyle, based on what cognitive testing shows.
Matthews: Just as it’s important to have your patient weigh in on developing goals, so is finding out what their interests are. Old habits can be hard to break, but in order to make treatment functional for patients, the tasks have to be relevant to their lives. The same treatment and stimuli should not apply to all patients with a similar profile. Sometimes changing the treatment materials to fit a patient’s interest can make a large impact on their motivation, participation and, ultimately, reaching their goals.
Eichhorn: There can be value in the use of some available materials. The key is to always remember the underlying skill you are attempting to teach your patient. You can use a worksheet and reflect on performance (i.e., how they solved the problem you gave).
Participant: Are there ways to effectively leverage the skills of physical therapists [PTs] and occupational therapists [OTs] to support our goals toward functional communication?
Matthews: Collaborate whenever possible. Our colleagues in rehab value their patients’ ability to communicate because this also impacts the progress they make in their therapies as well.
Eichhorn: Education and co-treatment! I work routinely with our PTs and OTs to model effective communication and training strategies—even for their goals. We are all a team, and working together brings about the most effective and positive outcomes for our patients.
Participant: I understand that workbooks are taboo when it comes to working toward functional targets. But are there similar ready-made treatment tools that are good starting points for treatment in a world where we are under increasing productivity demands?
Eichhorn: Workbooks are not taboo! Workbooks are not your treatment, but they can provide some materials you can use in a treatment session.
Matthews: They are not worthless, but they are not everything. Use them in moderation and know why you’re choosing what you’re choosing.

Workbooks are not taboo! Workbooks are not your treatment, but they can provide some materials you can use in a treatment session.

Participant: Is there a right/wrong time to introduce augmentative and alternative communication [AAC] as a treatment approach in those with degenerative conditions?
Matthews: The wrong time is when they are having significant difficulty with verbal communication. It’s never too early, especially because you may not be able to predict the timing of progression. Patients may not be ready, but at least they will know it’s an option early on. The more time they have to practice, the better and more likely they will be to use AAC.
Eichhorn: The literature supports early introduction. However, you must also take into account the needs and acceptance of the patient at the time and temper your intervention based on this. Sometimes just starting with education and counseling is the right thing to do, and then schedule a follow-up visit.
Participant: Any suggestions for what functional activities look like when the patients I work with do not have a place to be discharged to? (Many of the individuals I serve in my psychiatric facility are homeless.)
Eichhorn: This is often a situation that I encounter as well. I think that collaboration with social work regarding discharge plan can help drive your goal setting. Most certainly, problem solving can typically be targeted, but if the discharge plan is to somewhere such as assisted living or elsewhere, you may not have particular goals (i.e., may always require some level of supervision). Functional vocabulary is usually always a reasonable place to start.
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December 2016
Volume 21, Issue 12