Running head: LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 1

Learning Services Occupational Therapy Program

Brady Donner

University of Utah
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 2

Introduction

The purpose of this assignment is to accurately incorporate occupational therapy

principles and skills to create a program to serve an underserved population. The site that was

chosen for this specific program was Learning Services which is a residential facility for

individuals with Traumatic Brain Injuries (TBI). A needs assessment was performed through

interviews involving staff, program director, case manager, and residents. A literature review

was also completed that relates to the needs found. Residents’ functioning and life satisfaction

was assessed using interviews and occupational observation during one-on-one time with staff,

activities of daily living, and recreational activities at home and in the community.

Description of Setting

Learning Services has been treating people with brain injuries for over 30 years and now

has locations in five states including California, Colorado, Georgia, North Carolina, and Utah.

They are “founded on the belief that therapies should focus on the development of compensatory

strategies that enable individuals to function as independently as possible in the least restrictive

settings” (Learning Services, n.d.). Learning Services’ therapeutic services include

neurobehavioral rehabilitation, post-acute neurorehabilitation, supported living, and day

treatment rehabilitation. Their mission statement is “Learning Services is a national leader

dedicated to building futures for people with Acquired Brain Injury and those who support them

through person-centered, community integrated rehabilitation services.” As an organization,

Learning Services values person-centered service in the least restrictive environment possible,

providing extensive training to their staff, clear expectations and satisfaction for all stakeholders,

and respect for individuality and professional expertise (Learning Services, n.d.).
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 3

Learning Services’ Riverton, Utah program provides a supported living facility with

space for nine residents. Residents receive assistance with activities of daily living (ADL)

including self-care, meal preparation, and shopping. Service providers included in the Utah

program include medical director, case manager, life skills trainers, and off site occupational,

physical, and speech therapies. This program provides individual-based care with one-on-one

time for each resident to complete home programs created by occupational, speech, and physical

therapists. Residents have the opportunity to participate in activities in the facility as well as in

the community. They frequently enjoy community activities such as concerts, movies, and eating

out.

Target Population

The Utah Learning Services program provides services for males with acquired brain

injuries who are being funded by worker’s compensation. Since all of the residents are worker’s

compensation cases, most of them held employment positions such as truck driver or in the

construction industry. According to the Centers for Disease Control and Prevention (CDC), most

TBIs were caused by falls, followed by being “struck by or against an object,” and the third most

prevalent cause was car accidents (Centers for Disease Control and Prevention [CDC], 2017).

Males have more frequent incidents of TBI than females by 1.5 times and is also more common

in individuals with lower socioeconomic status (Neurotrauma Law Nexus, n.d.). Individuals with

previous concussions or brain injuries are also at a much higher risk of receiving another brain

trauma. Many of the residents at Learning Services are divorced or are separated from the

significant other they were with at the time of their injury. Since most injuries occurred when the

residents were young, many had small children who are now grown and have varying amounts of
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 4

contact with currently. These strained relationships are often a point of emotional pain for the

residents.

Symptoms of TBI vary depending on which part of the brain is injured and may include a

variety of manifestations in different cases. Because of this, each resident at Learning Services is

unique in the type of assistance they require. Symptoms that are present in the Utah Learning

Services program include cognitive impairments, behavior issues, speech difficulties, motor

control difficulties, vision impairments, and others.

External Influences on Services Provided

Geographic. Learning Services is located in a residential area of Riverton, Utah which is

located 20 miles south of Salt Lake City. Its location gives it quick access to I-15 which is the

major interstate that runs North and South through Utah, and Bangerter Highway which provides

access to the Western portion of the Salt Lake Valley. Riverton is a rapidly growing community

with a population of about 43,000 and Salt Lake County has a population of over one million.

This large population makes many resources available to the residents at Learning Services. Its

location near the Wasatch Front gives residents quick access to the mountains and different

adaptive recreational activities.

Policy. The Traumatic Brain Injury Act of 2014 (TBI Act) provides federal funding to

researchers in hopes to “(1) reduce the incidence of TBI; (2) conduct research on prevention,

treatment, and rehabilitation; and (3) improve access to rehabilitation and related services. The

law authorizes funding to carry out these activities by three agencies within the U.S. Department

of Health and Human Services (HHS)” (Brain Injury Association of America [BIAUSA], n.d.).

The CDC’s role is to provide information to the public to help with prevention of future injuries

and determine incidence and prevalence of the condition. The National Institutes of Health (NIH)
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 5

is provided with funding to conduct clinical research for the “prevention, diagnosis, and

treatment of TBI and the general management of trauma” (BIAUSA, n.d.). The Administration

for Community Living (ACL) conducts two programs for the TBI Act. The first provides

funding to states to increase access for housing. The second provides grants to the Protection and

Advocacy System in each state.

Sociocultural. Since Learning Services serves individuals with acquired brain injuries,

residents do remember what it was like to function at a higher level than they currently are. This

can be a barrier to their life satisfaction and cause frustration with their situation. Their

disabilities also may draw unwanted attention when they are in the community. Changes in their

abilities have affected each resident’s relationships with friends and family and they are often

aware of these changes especially with former significant others.

Social relationships, both positive and negative, have also developed within Learning

Services. Some of the residents have become close and will invite one another on community

outings, while others avoid sitting together even during meals. This is typical in any social

construct, but does have an influence on the way they are served in this setting. It determines

meal times and staffing.

Political. Salt Lake County tends to be the most liberal area of Utah, but is still primarily

conservative. Even among the residents in Learning Services, there are more conservative view

points which promotes small federal government and more power with local and state

governments. Ongoing shifts in the United States’ healthcare system can have an influence on

the type of care the potentially medically fragile residents of Learning Services.

Demographic. Salt Lake County, which includes Riverton, is over 98% Caucasian

followed by people of Hispanic descent (Data USA, 2018). Religiously, Riverton is

LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 6

predominately members of the Church of Jesus Christ of Latter-day Saints which is the dominant

religion throughout Utah. These demographics are reflected in the residents at Learning Services.

Economic. Riverton, Utah has a median house hold Salary of $87,806 which is

considerably above the national average and the average of Salt Lake County. Jobs within

Riverton vary from mining to retail to healthcare. There is a higher than the national average

wealth disparity in Riverton. Because Riverton is included in the greater metropolitan area, there

are many option for employment within a short distance which is beneficial to the economy in

the area (Data USA, 2018).

Internal Influence on Services Provided

Staffing. The staff who work for Learning Services predominantly consists of direct care

staff who assist residents with ADLs and ensuring safety. Staffing is often a barrier to care for

the residents due to a high turn-over rate. Frequently, staff are at points of transition in their lives

and will only work for the company for a short time. This causes disruption in the lives of

residents because they have to form new relationships frequently and it takes a considerable

amount of time to fully train a new staff member. The staff also includes the program manager

who care for the day-to-day operations of the facility and a case manager who is more in touch

with big picture items. Learning Services staff also includes a behavior analyst. There are no

occupational therapists, physical therapists, or speech language pathologists on staff at the

Riverton location. This is not typical for Learning Services throughout the country.

Related Services. Learning Services include outside services that are not staffed directly

by the company, which includes a yearly evaluation by occupational therapy, physical therapy,

and speech language pathology. These disciplines will complete the evaluation, create client-

centered goals and a program to be run by the staff at Learning Services. Each year the goals are
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 7

reviewed and changed to meet the needs of the resident. In larger Learning Services programs

there are full-time occupational, physical, and speech therapists on staff to meet the therapeutic

needs of the residents.

Residents also have access to any medical care that they require at any time. They also

have access to other services that are necessary for their functional progression. Several of the

residents attend a session of equine-assisted therapy each week to strengthen core muscles,

coordination, and range of motion.

Funding Sources. Learning Services is mainly funded through worker’s compensation

for workers who have acquired a TBI while on the job. Treatments are specific for each person

and can vary in cost depending on what that individual needs for their neurorehabilitation. This

depends on the level of supervision, medications, or other medical and therapeutic needs.

Learning Services works with a number of preferred workers compensation organizations and

networks including Paradigm, Liberty Mutual, and Employer Insurance Group to name a few

(Learning Services, n.d.).

Future Plans. Learning Services, Riverton has several ideas for expanding their business

and to diversify their funding. Currently they have too specific a clientele to expand their

company in the area. For 30 years they have worked exclusively with worker’s compensation for

individuals with TBIs. They are beginning to discuss opening up to private insurance companies.

There is also discussion of developing a day program to serve a wider population. A Learning

Services located in North Carolina also includes a pain rehabilitation program. This program is

evidenced-based and focused on “maximizing function and quality of life” (Learning services,

n.d.). Learning Services Riverton is interested in developing and implementing a similar program

here.
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 8

Current Program’s Strengths and areas for growth

Case Manager

A one-on-one semi-structured interview was conducted to get the perspective of the

managing case manager. She works more with the corporate company and has clearer view of

where they are wanting to take Learning Services. She is happy with the way this facility is being

run at this time and is interested in expanding the Utah program in different directs. She feels

that Learning Services could address transitions to home for acute TBI treatment to help those

individuals be more successful after their injury. She is also interested in moving into treating

other neurological conditions such as spinal cord injury, cerebrovascular accidents, and

addressing chronic pain. Expanding Learning Services here would allow them to hire full-time

therapists that could serve the residents directly and more regularly. The case manager also

expressed that she would like to have an occupational therapist on staff to help with adaptive

recreation that more of the residents would enjoy so that they could participate in more activities

with less staff.

Program Manager

A one-on-one semi-structured interview was conducted to get the perspective of the

program manager. He started at Learning Services about ten years ago and explained that the

focus at this facility has shifted from habilitation and maintaining functioning to rehabilitation

and improving functioning. He has extensively advocated for more one-on-one time for staff and

residents in order to spend more time on ADLs and running the programs that have been created

by occupational, physical, and speech therapists. This has resulted in substantial improvements

in functioning for many of the residents at Learning Services. He reported that he felt that one of

the strengths of this program is that their funding allows them to hire more direct care staff to
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 9

improve the staff to resident ratio to carry out programs created by therapists and have time to

cue residents to complete ADL tasks instead of completing them for them.

A gap that he sees in the services provided is a lack of consistent therapeutic

interventions by a therapist. He expressed that therapists often have a difficult time making

headway with the residents because of their behaviors. Therapists typically do not have enough

time to develop a relationship with the residents and understand their unique behaviors.

Direct Care Staff

One-on-one informal interviews were conducted with direct care staff to get their

perspective on the current program at Learning Services. Each staff member reported that they

liked the way that the company was run and thought that they were providing an important and

thorough service to the residents. The main concerns that were expressed were about being short

staffed or the high turn-over rate that is prevalent in this type of facility.

Residents

Residents were interviewed using a modified version Canadian Occupational

Performance Measure (COPM) in order to understand their occupational performance and life

satisfaction. Many of the residents are non-verbal so informal occupational and behavioral

observations were also conducted to see functioning and get a better picture of their daily lives.

In the interview residents expressed that they generally enjoyed the staff at Learning Services

and the service they provide. One resident left Learning Services for two years to go to another

company and returned because he realized that Learning Services is a much better program. He

articulated that he wished there was more recreational activities that met his interests more.

Residents are able to go shopping, visit family, attend movies, concerts, participate in adaptive
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 10

shooting, equine assisted therapy, and other recreational activities that allow them to live

fulfilling, enjoyable lives.

Graduate Student Perspective

Information about the Learning Services program in Riverton, Utah was gathered through

research on the Learning Services website, semi-structured interviews, casual conversations,

occupational and behavioral observation, personal experience working as a direct support staff at

another company, and a modified version of the COPM. The purpose of gathering this

information was to find strengths and weaknesses of the current program and search for gaps that

could be filled by an occupational therapist.

Strengths. Learning Services is unique in this field because it has a strong focus on

rehabilitation rather than just care and maintaining. There is also a strong focus on thorough

training for the staff on each resident and their unique deficits. During ADLs staff uses a

hierarchy of cuing rather than just completing the tasks for the resident. This helps the resident

improve their functioning. They are also trained in the residents’ home exercise programs,

adaptive equipment, and ADLs which allows them to always keep up on their therapies.

Learning Services also advocates for more funding to allow more resident one-on-one

staff time. They use documentation that shows progression in their residents which allows them

to have a stronger focus on rehabilitation. Throughout the day residents spend time with staff

walking and running up and down the halls, standing, and completing exercises on the mats.

Staff is able to take them out on an adapted tandem bicycle to help strengthen muscles and

coordination.

Areas for growth. Residents at Learning Services are evaluated by an occupational

therapist once a year. Goals and home programs are developed and the staff carry them out
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 11

within the facility. This focus on therapy is good, however the occupational therapy process

requires constant reevaluation and changes in plans for best therapeutic results. This is a major

area of growth in this program. If an occupational therapist could consistently work with the

residents their training would allow them to observe behaviors and progression in a way that a

direct staff would not. This would also prevent a loss of focus on each resident’s goals and help

them to improve functioning faster.

Another area that is lacking is a focus on recreational activities that include everyone’s

interest. This could help the residents have more meaningful lives and help with staffing issues.

It would also improve social relationship between residents, be a social outlet outside of

Learning Services, and build opportunities for community integration. Occupational therapists

are uniquely qualified to address adaptive recreation and finding ways for people of all abilities

to participate.

Because there is such a high turnover rate, there is a concern that training is not being

completed as thoroughly as would be ideal. In order to strengthen the quality of staff members

and services being provided, an occupational therapist could provide train and education on

specific home programs for residents, TBI, and some skills influenced by occupational therapy to

improve the residents’ direct care.

Another area that could be addressed is social participation with friends and family

outside of Learning Services. It has been reported that homes are not always accessible to the

residents and occasionally receive property damage from power wheelchairs. An occupational

therapist could complete home evaluation and provide feedback on what environmental changes

could be made to improve the accessibility of the home. This would limit the stress that could be
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 12

caused by having a resident visit family and increase the amount of social participation with

family members and friends.

All household chores are completed by staff at Learning Services so residents who are

capable are missing out on opportunities to learn to more fully participate in their lives.

Participation in household tasks could improve cognition, motor control, and prepare them to

eventually be able to live independently. An occupational therapist could train, consult, and

provide direct therapy with the residents at learning services.

Evidence-based Practice

A literature review was completed to develop an understanding of the occupational needs

of the residents of Learning Services and to collect evidence for occupational therapy for

individuals with traumatic brain injuries (TBI). American Journal of Occupational Therapy,

Google Scholar, and the University of Utah Library were the databases used to collect relevant

articles. The keywords used in this search included: occupational therapy, TBI, program, adults,

neurological condition, cognition, adaptations, outcomes, symptoms, severe TBI, moderate TBI,

community mobility, social participation, and motor function. Inclusion criteria was based on

how relevant the article was to the topic of research. Twelve articles were selected for this

literature review.

A literature review was performed to better understand the TBI populations, what deficits

they cause, and what services are required for their successful rehabilitation. This will allow for a

more accurate, evidence-based program to better serve the residents at Learning Services.

Traumatic Brain Injury

Epidemiology. According to the CDC, “TBI contribute to about 30% of all injury

deaths” (CDC, 2017). These injuries are more common in young men, and in moderate to severe
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 13

cases require some type of special medical or therapeutic services for the rest of their lives

(Maas, Stocchetti, & Bullock, 2008). This statistic is reflected at learning services where at the

time of their injury, six of the residents were in their 20’s or under, two were in their 40’s and

one was in his 70’s. Their injuries were caused by falls, assault, anoxia, motor vehicle accident,

and a bicycle accident. These injuries continue to challenge the residents in daily living skills and

require services because they are unable to live independently.

Chronic symptoms and consequences of TBI. Symptoms of TBI vary depending on

type of location of injury and can include “cognitive function, motor function, sensation, and

emotion” (CDC, 2017). The presentation of these symptoms also vary in severity and patients

may suffer from one of these symptoms or all of them. “An estimated 5.3 million Americans live

with TBI-related disabilities” (Huebner, Johnson, Bennett, & Schneck, 2003) which affects all

aspects of their lives including family and friend relationships, their ability to work, community

mobility, household management including bill paying, and independence in other activities of

daily living (ADL). Individuals with TBI’s have an increased risk of having social circles that

dwindle and have difficulty “reintegrating into the community socially” (Batchos, Easton, Haak,

& Ditchman, 2017). Integrating back into home life has also been shown to be a struggle of

persons with TBI. Research by Burleigh, Farber, and Gillard (1998) reported that “only about

half of all persons with moderate brain injury will return to school, work, and independent living

in one year after injury.”

Residents at Learning Services have a variety of deficits related to motor, cognitive,

sensation, and emotion. Several of the residents are wheelchair users, have behavior plans, and

have a number of mental health conditions such as post-traumatic stress disorder, or depression.

There is a focus in Learning Services on community integration, and many of the residents go on
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 14

frequent home or other social visits, however many have strained relationships with family and

friends.

Role of Occupational Therapy with TBI

Occupational therapists (OT) are especially qualified to work with individuals with TBI

because of the specialized training received to perform activity analysis and creatively adapt the

environment with a focus on enabling occupation. Knowledge of anatomy, neuroanatomy, and

kinesiology is also emphasized by OTs which provides practitioners with an understanding of the

condition and how it affects human physiology. OT interventions ultimately are created to

increase “participation and occupational engagement with the vision of promoting health,

productivity and quality of life” (Huebner, et al., 2003). Data collected from the residents at

Learning Services reflects a desire to be more engaged occupationally including basic ADLs like

dressing and grooming, recreational or leisure activities, community mobility, or social

participation.

Motor functioning is often dramatically affected by TBI (CDC, 2017) with deficits which

include “abnormal muscle tone, primitive reflexes, muscle weakness, ataxia, postural deficits,

and limited range of motion, resulting in difficulties engaging in purposeful activities” (Chang,

Baxter, & Rissky, 2016). Most of the residents at Learning Services have very significant motor

deficits caused by their injuries which affect their mobility and ability to complete ADLs. One of

the residents reported that he attempted to get his driver’s license, but failed his evaluation. A

large component of the reason for his failure was his decreased motor ability. Ponsford et al.

(2014) found that those who had limited mobility had more severe TBI. Several types of

interventions have been shown to be helpful when treating TBI patients with motor deficits.

Kinetotherapy has demonstrated the ability to assist people to strengthen core muscles and hand
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 15

function which benefits wheelchair mobility (Chang, et al., 2016). Home exercise programs can

also be developed by an OT and have a high success rate for improvement of motor functions

and decreasing spasticity. Chang, et al. (2016) found, however that an 8 week aquatic exercise

program was the only treatment that had significant improvement when compared with those in a

control group. Limited evidence was found for benefits for virtual reality games and Wii balance

games. These interventions did show some improvements in areas such as hand function and

balance, but it was inconsistent and the research had small sample sizes (Chang, et al., 2016).

One of the major challenges that comes with addressing motor function is that it is tied so closely

to sensory and cognition. Motor function, sensory, and cognition must all be incorporated in

order to have the desired outcomes (Chang, et al., 2016).

Cognition is integrated into all aspects of life and allows individuals to “concentrate,

think, remember, plan, problem solve, self-monitor, and execute goal-directed behavior”

(Radomski, Anheluk, Bartzen, & Zola, 2016). People with moderate to severe TBI experience

cognition deficits that interfere with occupation participation throughout the rest of their lives

Radomski, et al., 2016). Impairments can include problems in community integration, successful

vocation (Jackson, 1994), developing and maintaining social relationships (Powell, Rich, &

Wise, 2016), remaining financially independent (Koller, et al., 2016), independence in

community mobility (Lemoncello, Sohlberg, & Fickas, 2010), and others. OT is able to address

many areas of cognition including, executive functioning, attention, self-awareness, and

memory. Several studies reviewed in a systematic review by Radomski et al. (2016) found that

interventions addressing attention with individuals, in groups, goal-oriented attention regulation

training, and dual task training were all highly effective treatments for individuals with TBI

induced cognition impairments. The same study found that there is strong evidence supporting
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 16

executive functioning interventions including “goal management training and metacognitive

strategy instruction” (Radomski, et al., 2016). Boelen, Spikman, and Fasotti (2011) found that

interventions based on “compensatory, behavioral, and attention remediation” were effective.

Memory interventions with strong evidence include restorative and compensatory approaches,

using internal and external memory strategies, and errorless learning (Radomski, et al., 2016).

Memory strategies could include compensation like using checklists to complete a morning

routine, setting reminders for events on a cell phone, or using mnemonics to remember

directions. Lemoncello et al. (2010) found that using landmark direction rather than cardinal or

left and right direction was an effective cognitive strategy when navigating through the

community.

Social participation is an occupation that people with TBI struggle with (Powell, et al.,

2016). Changes in cognition, behavior, and emotion often cause strain on personal relationships.

Ponsford, Olver, Ponsford, and Nelms (2009) found that there were increased rates of depression

and anxiety in family caregivers of TBI patients. This was found in both parents and spouses.

Deficits in personal care, home management, and leisure or recreational activities make social

integration difficult and they often do not return to pre-morbid functioning (Powell, et al., 2016).

One study found that 85% of TBI patients residing in a supported living setting wanted more

social involvement (Condeluci et al., 1992). Cuthbert et al. (2015) found that there was a 60%

unemployment rate two years post injury for individuals with severe TBI. This puts limitations

on individuals’ life satisfaction and contributes to other mental health issues (Andelic, et al.

2010). With so much significant impairment to their social participation, it becomes imperative

that this area is addressed in this population.

LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 17

In a systematic review conducted by Powell et al. (2016), it was found that there were

five themes of interventions that addressed social participation and everyday activities which

included: “multidisciplinary and interdisciplinary treatment approaches, community-based

rehabilitation programs, treatment approaches using client-centered goals and relevant contexts,

social skills training and peer mentoring interventions and community mobility interventions.”

Multidisciplinary treatment approaches are usually found in inpatient settings, but this review

also found community-based interventions which included OT. These have moderate evidence

that shows that they are effective in improving the individual’s ability to live independently

including their social-emotional wellbeing (Powell, et al., 2016). Community-based programs

were in general found to support occupational function, social participation, and community

integration. Holistic day programs were especially supported in the research to enhance daily

functioning (Powell, et al., 2016). In a client-centered context relevant programs, Doig, Fleming,

Kuiper, Cornwell, and Kahn (2011) found gains in functioning when goal setting was client-

centered, had structured delivery, and included a realistic environment.

Peer mentoring interventions were found to have little evidence supporting them. Patients

actually reported higher levels of depressive symptoms which the authors attributed to higher

levels of awareness of TBI-related problems (Wheeler, Acord-Vira, & Davis, 2016). Social skills

training has weak evidence in improving social participation, emotional adjustment, or social

functioning, but had significant improvements in social behaviors (Wheeler, et al., 2016). In a

study by McDonald et al. (2008) social skills training failed to be effective in improving social

participation, but did “improve partner-directed behaviors such as reciprocal conversational

skills.” Community mobility is an important aspect of social participation and community

integration, however this is an area that has limited research conducted in it. One study used a
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 18

driving simulation, but did not have an assessment on-the-road which makes it difficult to

generalize (Powell, et al., 2016).

TBI Long-term Care

In a study by Burleigh et al. (1998) implications for long-term (8-23 years) services after

a TBI to address social problems showed that people with TBI often lose their social network

due to impairments in “judgment, self-awareness, social and sexual disinhibition, egocentricity,

anger control, substance abuse, and other problem behaviors.” In order to prevent shrinking of

their social network it is important to educate family, friends, and coworkers of “fundamentals of

head injury” (Krefting, 1989). Addressing these psychosocial concerns would work to increase

the life satisfaction of someone with a TBI.

One way to create a social support system is through long-term supportive living. This

system allows the individual to develop relationships with peers and caregivers in a safe

environment. It opens up opportunities for adaptive recreation, community integration, and

continued therapy services. Jackson (1993) found that “insurance companies may advocate” for

these types of settings because they are safe and minimize the risk of further injury. Supported

living programs run the risk of social, vocational, and recreational isolation. These issues must

be addressed and it has been found that many facilities are providing more services to facilitate

these critical components (Jackson, 1993).

In a longitudinal study that followed up with TBI patients after 10 years it was found that

there was still a significant need for rehabilitation services (Ponsford, et al., 2014). This study

reported that there was a strong focus on physical rehabilitation, but therapy for cognitive, social,

and behavioral problems were not addressed as well. These issues often go unaddressed because

staff have limited knowledge or experience with this population. With this population, in order to
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 19

have positive long-term outcomes over the life span, it is important that strategies for healthcare

services and goals be implemented (Andelic, et al., 2018). Often there is a strong focus on early

rehabilitation, but the need exists for OT services across the life span to address motor skill,

social participation, and cognition.

Summary

Learning Services is “founded on the belief that therapies should focus on the

development of compensatory strategies that enable individuals to function as independently as

possible in the least restrictive settings” (Learning Services, n.d.). The Riverton, Utah program

exemplifies this sentiment and uses the resources it has to improve the lives of the residents.

Although they do an excellent job with home exercise programs that are created specifically for

each resident, they do not receive consistent OT services throughout the year.

Through the literature review it was discovered that individuals with TBI suffer from a

variety of impairments including motor, social and emotional, behavioral, and cognitive. These

deficits often affect the individual throughout the life span and require interventions which are

often provided by an OT. It has also been found that 70% of long-term supported living facilities

for TBI offer OT services (Jackson, 1993). All but two of the Learning Services programs have a

full-time OT on staff which includes the Riverton program. This is something that the case

manager reported that she felt was important to change.

OT aims to “promote health productivity, and quality of life for individuals with

disabilities” (Huebner, et al., 2003). In this setting having a consistent OT would be beneficial

because the residents would become familiar with them, the OT would learn to manage with

negative behaviors, and residents would receive services to increase their independence in ADLs.
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 20

Each resident at Learning Services has unique deficits and therefore, requires individualized

treatment intervention to address motor, social and emotional, and cognitive impairments.

Based on the combined information from the needs analysis and the literature review, an

OT program at Learning Services would be appropriate to increase the independence and life

satisfaction of the residents. This program would fill the needs of the facility that have been

identified through student observation, and interviews with staff, program manager, case

manager, and residents. This program would support the mission on Learning Services and

enable occupations in the residents.

Program Proposal: Learning Services Occupational Therapy Program

Program Overview

Currently, Learning Services has a good program that focuses on rehabilitation of its nine

residents with traumatic brain injuries (TBI). However, the residents at Learning Services would

benefit from additional services from an occupational therapist to fill in the gaps that were found

in the needs analysis. The literature review showed that occupational therapy services across the

life-span in long-term residential facilities can be very beneficial to the daily functioning of

individuals with TBI. This type of program will strengthen an already well developed focus on

the rehabilitation of the residents at Learning Services. The program which is being proposed

emphasizes the continued rehabilitation of the residents, focuses on their social participation by

advocating for them with their families and friends, and builds the skills and knowledge of the

staff through education and training.

The direct service that would be provided to the residents would include frequent

evaluations, goal oriented, and evidence-based therapy services with emphasis placed on

enabling occupation. Currently, residents at Learning Services are evaluated by an occupational

LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 21

therapist once a year. Goals and a home program are developed for staff to carry out. Staff are

given hand-outs to explain the home exercise program. However, even with these evaluations

and home exercise programs, little progress has been shown. With consistent evaluations and

treatment being provided by a familiar occupational therapist, growth can be achieved which will

improve the resident’s occupational engagement and quality of life.

In order to advocate for the residents, home evaluations would be performed for the

family members and friends who are frequently visited by the residents. These evaluations would

be focused on the accessibility of homes and giving advice on how to prevent property damage

caused by power wheelchairs that are used by many of the residents. This will improve the social

participation of residents with individuals outside of the facility because family and friends

would feel more comfortable after receiving consultation from an occupational therapist.

A key component of the achieving successful outcomes in Learning Services is the

training and knowledge of the direct care staff. Employees at Learning Services could greatly

enhance the rehabilitation potential of the residents with the proper training. This training would

be focused on cueing, home exercise program techniques, and other aspects of health that affect

individuals with TBI. Training and education will have a powerful influence on the rehabilitation

success of the residents.

Program Value

This program aims to improve the services provided to residents at Learning Services by

adding consistent occupational therapy, home evaluations for family of residents, and increased

training for direct care staff within the facility. This would increase the residents’ occupational

participation in activities of daily life, allow family and friends to feel more comfortable with

having the residents come into their home for visits, and give them more consistent and skilled
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 22

therapy services through staff training and education. This perfectly aligns with Learning

Services’ mission statement which is to “[build] futures for people with acquired brain injury and

those who support them through person-centered, community integrated rehabilitation services.”

They also have a focus on the “development of compensatory strategies that enable individuals

to function as independently as possible in the least restrictive setting” (Learning Services, n.d.).

Occupational Justice. Often times in residential facilities similar to Learning Services,

residents have limited access to the community or social activities due to staffing issues or other

problems related to the individual’s condition. This occupational therapy program aims to

change this instance of occupational deprivation by increasing their independence in occupations

such as activities of daily living, recreation, or leisure activities and social participation.

Providing occasions to participate in the maintenance of their home will also allow them to

engage in meaningful occupations and develop life satisfaction. Creating opportunities for the

residents to choose new and interesting recreation or leisure activities will decrease their

occupational deprivation.

In many similar ways, the residents of Learning Services are also dealing with

occupational marginalization. This occurs when individuals are not given the opportunity to

participate in occupations when, where, and how based on social norms. Many of the residents

are secluded from participating in work, family roles, close friendships, and leisure activities that

are normal for people their age. This program aims to enable some of the occupations through

compensatory strategies, education of family and friends, and improved training of staff

members.

Addressing these occupational injustices will improve the health of the residents by

improving their self-worth and efficacy and through using occupations as a therapeutic activity.
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 23

Increasing the independence in activities of daily living and other occupations will cause the

residence to have improved mental health. Engaging in occupations can also have physical and

cognitive implications. Repetitive movements can increase motor function and cognition can be

improved through activities as well. Adaptations can also be made to improve occupational

participation where motor and cognitive functioning fails.

Prevention. This program primarily focuses on tertiary preventions due to the

population. This program will provide direct occupational therapy to individuals with TBI to

improve their independence, safety from further injury, and help prevent psychosocial conditions

such as depression or anxiety. This program will also provide further training to staff which

could include transfer training to prevent injury in the resident and the staff member. A focus on

prevention of injury of staff members would be considered primary prevention because it focuses

on a healthy population who is at risk.

Residents may also receive training in items such as fall prevention. Because many of

them are a fall risk, this would be considered secondary prevention. Residents would receive

further training to ensure their safety and avoid injuries due to falls or other dangers.

Rationale for Occupational Therapy’s Role

Individuals with TBI often have motor deficits and have difficulty participating in their

pre-injury occupations due to these deficits and other barriers in the environment. These motor

deficits may include abnormal tone, muscle weakness, ataxia, postural deficits, and problems

with mobility. Cognitive deficits are also common among people with TBI and include problems

with memory, concentrating, planning, problem solving, self-monitoring, and several others.

As was shown in the literature review portion, occupational therapy has been shown to

have positive effects when used to treat individuals with TBI. Occupational therapy practitioners
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 24

have a focus on education in human anatomy, neuroanatomy, cognition, and kinesiology with an

emphasis on increasing participation and occupational engagement. On top of the physical

aspects of a person, occupational therapists are also concerned with the individual’s values,

beliefs, and spirituality. Occupational therapists are trained to look at the transaction between the

person, the activity, and the environment. This allows them to view a person holistically and see

what aspects of their well-being need to be addressed in order to enable meaningful occupation.

The residents at Learning Services have deficits in many of these areas and would benefit

from being evaluated and treated regularly by an occupational therapist because of their specific

skill set. The residents are in a unique position that brings them out of the community and creates

an environment where it is difficult for them to make their own decisions due to different

circumstances including staffing. An occupational therapist is especially qualified to incorporate

their desired occupations, environment, and their conditions to treat them and improve quality of

life and enable the occupations they want and need. These occupations include social

participation, activities of daily living, leisure and recreation, work, rest and sleep, and others.

Individuals with TBI are very unique when compared with other conditions that cause

disability. Their symptoms vary from person to person depending on where and how the injury

took place. Often behavioral deficits are also a major component that needs to be considered and

understood when interacting with this population. The occupational therapist who holds this

position should be aware of these considerations and have prior experience with TBI.

Theoretical Foundation.

In order to properly frame OT services in this setting, several models will be used to

contribute to the evidence-based nature of the program development. These models include

Person-Environment-Occupation (PEO) model, Model of Human Occupation (MOHO), and the

LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 25

Dynamic Interactional Model (DIM). These models allow an OT to address the person,

environment, and occupation, and improve motor function, cognition, and volition. They also

allow for adaptations to be made and to train individuals to develop their own solutions to

problems they encounter.

The Person, Environment, and Occupation Model (PEO) applies to individuals who are

not satisfied with their current occupational performance because an incongruence between the

person, environment, and occupation (Law, et al., 1996). PEO postulates that a person’s beliefs

about the environment and occupations influences their occupational performance. This makes it

important to understand their perspective and priorities in order to enable occupation. The

understanding of barriers that an individual is dealing with allows an occupational therapist to

address the transactional problems between person, environment, and occupation. By addressing

these barriers, the individual will become more functional in their daily life. This model will be

used to evaluate and treat the residents at Learning Services and frame how this evaluation is

completed. Occupational observation and environmental evaluations will be used to find areas

that have a lack of congruence. The Canadian Occupational Performance Measure (COPM) will

also be used to get the resident’s perspective on where incongruences may lie. The COPM is an

assessment that is in the form of a semi-structured interview that addresses several occupational

areas and addresses the level the individual feels they are functioning and how satisfied they are

with that level.

The Model of Human Occupation (MOHO) is a broad theoretical model that will be used

in this program to guide evaluation and treatment. MOHO focuses on addressing volition,

maintaining positive involvement in life roles, skilled performance of life tasks, the influence of

physical and social environments, and occupational adaptation and applies to any individual who
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 26

struggles in any of these areas. MOHO postulates that a person’s character and the environment

are linked together to create the whole person. It also postulates that a person’s way of

completing a task or activity and their routine influences the way they think and feel. Addressing

the Learning Services resident’s volition and life roles can have a positive impact on their self-

efficacy and how they feel about themselves generally. MOHO will be used to evaluate through

resident self-reporting, observations, and discovering their interests through unstructured

conversation (Kielhofner, 2009).

The Dynamic Interactional Model (DIM) addresses cognition and strives to decrease

activity limitations and enhance participation in everyday activities. It does this through focusing

on the interactions between person, activity, and environment similar to PEO. It states that

performance can be improved through changing the demands of an activity, environment, and

person. It focuses on assisting the individual to create cognitive strategies which helps them gain

“buy in.” If done correctly, this helps the individual to develop self-efficacy. Many of the

residents at Learning Services have cognitive impairments and DIM will help address these

deficits. The Performance of Self-care Skills (PASS) will be used to assess their cognition and

falls under the theoretical idea of DIM. The PASS is a dynamic assessment that uses everyday

activities to evaluate and address cognitive and physical functioning (Togila, 2009).

Goals and Objectives

Goal 1. To improve the quality of life and independence of the residents at Learning Services

through direct occupational therapy.

Objective 1. Within 6 months, 80% of the residents at Learning Services will increase

their ADL independence.

LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 27

Objective 2. Within 6 months, 80% of the residents at Learning Services in improve their

social interaction skills, as demonstrated by a decreased amount of conflicts between

residents and others.

Goal 2. To improve the staffs knowledge of traumatic brain injuries, and a therapeutic approach

to the direct care of residents at Learning Services.

Objective 1. Within 6 months, 80% of staff will independently implement the hierarchy

of cueing with residents during assistance with ADLs.

Objective 2. Within 6 months, 80% of staff will follow a home program provided by the

occupational therapist.

Learning Services Occupational Therapy Program

Learning Services is a residential facility for males with TBI that were work related. This

program has been developed to provided skilled and consistent occupational therapy to the

residents at Learning Services, assist with adaptive leisure and recreation, provide home

evaluations for those that are frequently visited by residents such as family, and provide training

and education to direct care staff. This program requires a part-time occupational therapist to

provide these services. Eligibility for this program will be based on residency or employment at

Learning Services.

Currently, residents at Learning Services have minimal access to skilled occupational

therapy. They are evaluated once a year to create new goals and home program. It is then up to

the staff at Learning Services to provide the therapy that is prescribed by the occupational

therapist. This program will provide a part-time occupational therapist to be employed by

Learning Services to provide direct therapy to the residents. The program will begin by

evaluating each resident. The evaluation will include reviewing current documentation,
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 28

observation of occupations, and assessments including the PASS and COPM. The evaluation

stage of the program will happen over about a month and then switch over to more treatment

centered sessions. During this time goals and home programs will be developed in collaboration

with the resident and the occupational therapist. The goals and home program can be changed at

any time, but are required to be updated at least every six months in order to encourage

progression and reevaluation. Interventions for this program will specifically address cognition,

motor function, and social participation. By addressing these areas, the patient will become more

independent in activities of daily living and increase their life satisfaction through engaging in

meaningful occupations. Scheduling of these treatment sessions are dependent on the schedule of

the residents. Each Resident will get at least one, one hour session per week. Occupational

therapy sessions will likely be completed over at least two separate days of the week in order to

see each resident. Treatment within the community will be encouraged in order to allow

residents to increase independence in community mobility by going to places such as grocery

stores, malls, restaurants, or the homes of family members. This will provide the opportunity for

the occupational therapist to address cognitive, motor, and social concerns that residents have.

Resources such as UTA public transportation will be used.

One area of need that was identified by the program manager, case manager, and

residents is creating more opportunities for adaptive recreation or leisure. Residents have limited

opportunity to enjoy recreational activities due to their deficits and staffing. If only one resident

wants to participate in an activity, then it is likely that he will not be able to because of staffing

limitations. If the residents of Learning Services could be placed in groups of individuals with

similar interests, they would have more opportunity for recreation. Occupational therapists are

experts in evaluating the environment, occupation, and person to adapt the activity and make it
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 29

more accessible to people with disabilities. They are also knowledgeable about resources

available to people with disabilities? in finding ways to adapt recreation such as the American

Occupational Therapy Association (AOTA) which allows therapists to consult with others and

share ideas. This service is called CommunOT and is available to all member of AOTA. This

program would have a small component of assisting Learning Services with finding resources

and ways to adapt leisure and recreational activities. This aspect of the program would take about

one to two hours per week to learn from the residents what their interests are and how they could

be paired with other residents. It would assist residents to be more active in the community and

provide opportunity to increase social participation and exercise. This would increase their

physical and social well-being.

Another gap in service that was identified by the case manager is home evaluations for

friends and families of Learning Services residents to increase the accessibility and to protect

their home from damage caused by power wheelchairs and other adaptive technology used by the

residents. Many family members have reported damage to walls caused by wheelchairs and an

evaluation would provide recommendations to family members on how they may be able to

prevent some of this damage or increase the accessibility of the home. The amount of time it will

take depends on the willingness on individuals to allow the occupational therapist to visit their

home and conduct the evaluation. This would lower the stress levels of family and friends of the

residents which would, in turn increase the social participation of the resident.

Residential facilities often have significant staffing issues and frequently have high staff

turnover rates are high due to the funding problems. One of the roles of the occupational

therapist in this program will be to assist in the training of new staff on how to care for the

residents. Additional training will be provided to the whole staff to raise the level of competence
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 30

with completing the home programs of the residents. Written instructions with diagrams will

continue to be provided as a reminder, but primarily training will be provided directly from the

therapist. Training will also include Hierarchy of Cuing (Appendix B) used in the PASS to assist

staff in providing support during activities of daily living such as bathing and dressing. This will

increase the quality of care and rehabilitation being provided to the residents and strengthen the

continued focus on occupational therapy goals. With this strong emphasis on occupational

therapy, residents will become more independent which will be a benefit to staffing by easing the

burden placed on them. Time requirements for training will depend on how many new staff are

hired and how frequently the home programs change. An estimated one to three hours will be

dedicated to this each week. This will also be front loaded early on as new programs are

developed that everyone needs to be trained on. During the first month this will likely take closer

to five to six hours a week.

Program start up. As the program begins a training will be provided to staff to explain

the role of occupational therapy at Learning Services and train them on what their role will be in

supporting this program. This will assist in getting the staff to buy in and give them an

understanding of how the program will work. The occupational therapist will also spend a little

time introducing themselves to the residents and getting to know them a little bit. They will also

review their documentation to gain a knowledge of the residents.

Space requirements. Since Learning Services already exists and the program only calls

for a part-time occupational therapist, space requirements will be minimal. All that will be

required is a little shelf space to store assessments and binders holding information on the home

program. There is a staff office where documentation can be completed and treatments will take

place around the facility or in the community.

LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 31

Time requirements. Over the first month or two, the time required to start the program

will be about 40 hours per week. This will allow the occupational therapist to meet, train,

evaluate, and organize the staff and residents. After the initial set up is complete, they will move

down to part-time hours estimated to be about 20 hours per week. The schedule may be changed

or altered depending resident’s scheduling conflicts and the desires of the occupational therapist.

This program is set up to run indefinitely or until Learning Services deems in necessary to end

the program.

Program marketing. Learning Services currently has a website that advertises

occupational therapy services as a part of their program. Since there is little residential turnover,

broad marketing will not be necessary. It will, however be the responsibility of the occupational

therapist to advocate for the service they provide and get the buy in from Learning Services and

the residents and their families.

Budget. Since the facility is already present and most of the services provided will occur

at the facility, there are not many items that need to be budgeted for. The therapist is part-time so

Learning Services will only need to pay their hourly wage with no benefits. Start-up costs will

include a month of full-time hours. The hourly wage of the therapist has been set at $30.00 per

hour in order to remain competitive. The increased hours at the beginning of the program will

total an extra $2,400. The normal rate will total to $31,200 for the year. The cost of the PASS is

about $40.00 and several copies of the COPM will cost $25.00. The total cost for the assessment

is $65.00. This will provide enough materials to last indefinitely. This places the first year’s total

cost at $33,665. A line-item budget can be found in Appendix C.

Funding Options.
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 32

Historically, the Riverton Learning Services program has received all of their funding

from the residents’ worker’s compensation insurance and have found ways to budget for

different disciplines to provide services to their residents. However, if they choose to seek out

grants to fund the occupational therapy program they could fund it through two different

resources. The first funding source found is through United States Department of Health and

Human Services. The second source found is Minneapolis Foundation. These grant sources were

found using the search engine “Foundation Directory” using the keywords “Brain and Nervous

System Disorder, Acquired Brain Injury.” Both organizations have provided funding for similar

programs and for similar conditions throughout the country.

Program evaluation

The efficacy program will be evaluated in several ways. First, evaluations of residents,

goals, and treatment sessions will be documented using SOAP notes to outline progression. Then

the Goal Attainment Scale (GAS) will be used to document improvement in the resident’s goals.

The GAS can be found in Appendix D. The GAS will be filled out following each session to

document how the resident is progressing on each of his goals.

The second way the efficacy of the program will be assessed is by repeating the COPM

with the residents ever six months. This will determine how they feel their functioning is and

how satisfied they are with that occupational performance. This will be documented and can be

later compared to find out if their satisfaction and occupational performance are improving.

The final way the program will be evaluated it through both qualitative and quantitative

questionnaires. There are different questions for residents, staff, and for management. Qualitative

questions are open ended questions and qualitative questions are based on a Likert scale of 1-5
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 33

where 1 is “not satisfied” and 5 is “very satisfied.” These questions can be found in Appendix E

and will be given every six months.

Expected outcomes. The expected outcomes for this program are that the residents at

Learning Services will become more independent and have a higher life satisfaction through

enabling occupation and building self-efficacy. This program also aims to develop life skills in

the residents of Learning Services and allow them to participate more fully in their decision

making and self-care. Staff will feel empowered in their positions and feel that they can make a

difference through principles based in occupational therapy. Staff burden will also drop due to

more independent residents.

LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 34

References

Andelic, N., Sigurdardottir, S., Schanke, A., Sandvick, L., Sveen, U., & Roe, C. (2010).

Disability, physical health and mental health 1 year after traumatic brain injury.

Disability and Rehabilitation, 32(13), 1122-1131. doi: 10.3109/09638280903410722

Andelic, N., Howe, E., Hellstrom, T., Sanchez, M., Lu, J., Lovstad, M., & Roe, C. (2018).

Disability and quality of life 20 years after traumatic brain injury. Brain and Behavior.

doi: 10.1002/brb3.1018

Batchos, E., Easton, A., Haak, C., & Ditchman, N. (2018). Social factors predictive of social

integration got adults with brain injury. Disability and Rehabilitation, 40(17), 2062-2069.

https://doi.org/10.1080/09638288.2017.1326175

Boelen, D. H., Spikman, J. M., & Fasotti, L. (2011). Rehabilitation of executive disorders after

brain injury: Are interventions effective? Journal of Neuropsychology, 5, 73–113.

http://dx.doi.org/10.1348/174866410X516434

Brain Injury Association of America. (n.d.). Traumatic brain injury act. Retrieved from

https://www.biausa.org/public-affairs/public-policy/traumatic-brain-injury-act

Burleigh, S., Farber, R., & Gillard, M. (1998). Community integration and life satisfaction after

traumatic brain injury: Long-term findings. American Journal of Occupational Therapy,

52, 45-52. doi:10.5014/ajot.52.1.45

Centers for Disease Control and Prevention. (2017, April 27). TBI: Get the facts. Retrieved from

https://www.cdc.gov/traumaticbraininjury/get_the_facts.html

Condeluci, A., Ferris, L., & Bogdan, A. (1992). Outcome and value: The survivor's perspective.

Journal of Head Trauma Rehabilitation, 7, 37-45.

LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 35

Chang, P.-F. J., Baxter, M. F., & Rissky, J. (2016). Effectiveness of interventions within the

scope of occupational therapy practice to improve motor function of people with

traumatic brain injury: A systematic review. American Journal of Occupational Therapy,

70, 7003180020. http://dx.doi.org/10.5014/ajot.2016.020867

Cuthbert, J. P., Harrison-Felix, C., Corrigan, J. D., Bell, J. M., Haarbauer-Krupa, J. K., & Miller,

A. C. (2015). Unemployment in the United States after traumatic brain injury for

working-age individuals: Prevalence and associated factors 2 years post injury. Journal of

Head Trauma Rehabilitation, 30, 160–174.

http://dx.doi.org/10.1097/HTR.0000000000000090

Data USA. (2018). Riverton, UT. Retrieved from https://datausa.io/profile/geo/riverton-ut/#top

Doig, E., Fleming, J., Kuipers, P., Cornwell, P., & Khan, A. (2011). Goal-directed outpatient

rehabilitation following TBI: A pilot study of programme effectiveness and comparison

of outcomes in home and day hospital settings. Brain Injury, 25, 1114–1125.

http://dx.doi.org/10.3109/02699052.2011.607788

Huebner, R. A., Johnson, K., Bennett, C. M., & Schneck, C. (2003). Community participation

and quality of life outcomes after adult traumatic brain injury. American Journal of

Occupational Therapy, 57, 177–185.

Jackson, J. (1994). After Rehabilitation: Meeting long-term needs of persons with traumatic

brain injury. American Journal of Occupational therapy, 48, 251-255.

doi:10.5014/ajot.48.3.251

Kielhofner, G. (2009). The model of human occupation. Conceptual foundations of occupational

therapy practice (4th ed.) (pp. 147-174). Philadelphia, PA: F.A. Davis Company.
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 36

Koller, K., Woods, L., Engel, L., Bottari, C., Dawson, D. R., & Nalder, E. (2016). Loss of

financial management independence after brain injury: Survivors’ experiences. American

Journal of Occupational Therapy, 70, 7003180070.

http://dx.doi.org/10.5014/ajot.2016.020198

Krefting, L. (1989). Reintegration into the community after head injury: The results of an

ethnographic study. Occupational Therapy Journal of Research, 9, 67-83.

Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The Person-

Environment-Occupation Model: A transactive approach to occupational performance.

Canadian Journal of Occupational Therapy, 63, 9-23.

Learning Services. (n.d.). About Learning Services. Retrieved from

https://learningservices.com/about-us/

Learning Services. (n.d.). Workers’ compensation insurance. Retrieved from

https://learningservices.com/funding-sources/workers-compensation-insurance/

Learning Services. (n.d.). Pain rehabilitation. Retrieved from

https://learningservices.com/programs/pain-rehabilitation/

Lemoncello, R., Sohlberg, M., & Fickas, S. (2010). How best to orient travelers with acquired

brain injury: A comparison of three directional prompts. Brain Injury, 24(3), 541-549.

doi: 10.3109/02699051003610425

Maas, A., Stocchetti, N., & Bullock, R. (2008). Moderate and severe traumatic brain injury in

adults. The Lancet Neurology, 7(8), 728-741. https://doi.org/10.1016/S1474-

4422(08)70164-9

McDonald, S., Tate, R., Togher, L., Bornhofen, C., Long, E., Gertler, P., & Bowen, R. (2008).

Social skills treatment for people with severe, chronic acquired brain injuries: A
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 37

multicenter trial. Archives of Physical Medicine and Rehabilitation, 89, 1648–1659.

http://dx.doi.org/10.1016/j.apmr.2008.02.029

Neurotrauma Law Nexus. (n.d.). Facts, demographics and risk factors. Retrieved from

http://www.neurolaw.com/traumatic-brain-injury/facts-demographics-risk-factors/

Ponsford, J., Downing, M., Olver, J., Ponsford, M., Acher, R., Carty, M., & Spitz, G. (2014).

Longitudinal follow-up of patients with traumatic brain injury: Outcome at two, five, and

ten years post-injury. Journal of Neurotrauma, 31, 64-77. doi: 10.1089/neu.2013.2997

Powell, J., M., Rich, T. J., & Wise, E. K. (2016). Effectiveness of occupation- and activity-based

interventions to improve everyday activities and social participation for people with

traumatic brain injury: A systematic review. American Journal of Occupational Therapy,

70, 7003180040. http://dx.doi.org/10.5014/ajot.2016.020909

Radomski, M. V., Anheluk, M., Bartzen, M. P., & Zola, J. (2016). Effectiveness of interventions

to address cognitive impairments and improve occupational performance after traumatic

brain injury: A systematic review. American Journal of Occupational Therapy, 70,

7003180050. http://dx.doi.org/10.5014/ajot.2016.020776

Toglia, Joan (2011). The dynamical interactional model of cognition in cognitive rehabilitation.

In N. Katz (Ed.), Cognition, occupation, and participation across the lifespan:

neuroscience, neurorehabilitation, and models of intervention in occupational therapy

(pp. 161-195). AOTA Press.

Wheeler, S., Acord-Vira, A., & Davis, D. (2016). Effectiveness of interventions to improve

occupational performance for people with psychosocial, behavioral, and emotional

impairments after brain injury: A systematic review. American Journal of Occupational

Therapy, 70, 7003180060. http://dx.doi.org/10.5014/ajot.115.020677

LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 38

Appendix A: Interview Questions

Administration Questions

-How does Learning Services keep track of progress made in goals of residents?
-What areas do you feel could be improved in Learning Services?
-How does Learning Services focus on the rehabilitation of its residents?
-What is Learning Services goal for its residents?
-What needs does Learning Services have?
-What is the purpose of your organization? (Mission statement, philosophy, etc.)
- What are some of the characteristics of this group? Diagnoses, LOS, what other services do
they usually get?
- What are your funding sources?
- What kinds of programming/services do you currently offer?
- What plans for different or additional services, etc.in the future?

Staff Questions

-How does Learning Services keep track of progress made in goals of residents?
-What areas do you feel could be improved in Learning Services?
-What needs does Learning Services have?
-What do you like about Learning Services?

Appendix B: Hierarchy of Cuing

Hierarchy of Types of Cueing/Assistance
Adapted from Performance Assessment of Self-Care Skills (PASS)
Authors: Joan C. Rogers, PhD, OTR/L, FAOTA, ABDA &
Margo Holm, PhD, OTR/L, FAOTA, ABDA

When task completion cannot be performed independently, the therapist provides the
minimal type and amount (frequency and duration) of assistance to facilitate task
performance, safety, and an adequate outcome.

Helps you to find the right amount of assistance and it helps to find what strategies a person
might need to complete the task independently as possible.

Verbal Supportive: verbal affirmations of the person’s ability to initiate, continue, or

complete a task. Verbal encouragement examples are (sometimes slip) good job, keep going,
you’re awesome. Only counts if they need to say it.

Verbal non-directive: Verbal cues to facilitate task initiation, or further task completion,
without telling the patient exactly what to do. Examples might be: are you missing anything?
(often in the form of a question).
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 39

Verbal directive: verbal statements informing the person how to initiate, continue, or
complete a task. Examples include: get your keys, move that closer (telling the person
exactly what you want them to do).

Gesture: Non-verbal communication intended to inform the person on how to initiate,

continue, or complete a task, which may be accompanied by verbal statements. Examples
could include: pointing at something

Task object or environmental rearrangement: Therapist manipulation of task objects or

the task environment to facilitate initiation, continuation, or completion. Rearrangement may
be accompanied by verbal statements. Examples of this would include
Therapist moves something so that the client can finish the task.

Demonstration: Modeling, with verbal statements if appropriate, to illustrate how to initiate,

continue, or complete a task. Demonstration examples include MODELING! (using the
materials) they don’t know how to do the thing and they’re being shown

Physical guidance: Movement of a person’s body or extremity as needed to facilitate an

action to promote task initiation, continuation, or completion, which may be accompanied by
verbal statements. For example:
HOH, manipulating their body to facilitate the task (adjusting pen, moving fingers)

Physical support: Physical contact with the person to support the body or extremity to
promote task initiation, continuation, or completion which may be accompanied by verbal
statements. Physical support examples include supporting part of the activity. Holding pot
handle to move boiling water to the sink because they couldn’t lift it.

Total assist: Therapist does the task for the person. The therapist compensates for the
person’s disability as appropriate for the underlying impairment. A total assist for one task
may enable the person to proceed with another task that is not as difficult for the person.
Examples of how to use total assist are reading the direction on the oatmeal box for them, cut
through the carrot because they can’t push it down.
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 40

Appendix C: Line-Item Budget

Source of Specific costs or sources of Cost

income
Start-up Costs Extra hours to create documentation $2,400
system, evaluations of residents, and other
program development.

Total= $2,400
Direct Costs
Personnel Salary $30.00/hour= $31,200/year
PASS $40
COPM APP ($10 activation+$15 for 100 $25
assessments)

Total= 31,265
Indirect Costs
Facility is already existing and OT will not
need exclusive space.

Income

Total=
Budget Summary
Total costs $33,665

Total income or Facility will be provided by Learning

in-kind Services which includes space and utilities.
contributions Computer for documentation also provided
by Learning Services.
Net cost of $33,665
program
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 41

Appendix D: Goal Attainment Scale (GAS)

GOAL ATTAINMENT SCALE

Client: Therapist:
Goal/Eval Date:
Goal Attainment Scale Worksheet

Goal 1:
Distal Outcome -2 -1 0 +1 +2
(Baseline) (Goal)
Much Less Less Expected Better Much Better
Level
(Target
Behavior)

Proximal Measurement Criteria Baseline

Outcomes
1) 1) 1)
2) 2)
3) 3)

2) 1) 1)
2) 2)
3) 3)
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 42

Appendix E: Questionnaires for Residents, Staff, and Management

Qualitative Questions:

 Residents
o What have you learned since working with the OT?
o What areas have you become more independent in?
o How has your functioning improved (motor, cognition, social)
 Staff
o What have you learned in trainings from the OT?
o How has training with the OT improved your care of the residents of Learning
Services?
o What would you change about your training?

Quantitative Questions: All questions are on a scale of 1-5, 1 being not satisfied, 3 being
neutral, and 5 being very satisfied.
 Residents
o How satisfied are you with your occupational therapy services?
 Staff
o How satisfied are you with the training provided to you by the OT?
o How satisfied are you with your own performance of care of the residents at
learning services?
 Manager
o How satisfied are you with the training provided to your staff?