Professional Documents
Culture Documents
Brady Donner
University of Utah
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 2
Introduction
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
dedicated to building futures for people with Acquired Brain Injury and those who support them
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
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
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
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
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
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
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
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
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
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,
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
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
Case Manager
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
Program Manager
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.
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.
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
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
Information about the Learning Services program in Riverton, Utah was gathered through
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
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.
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
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
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
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
Evidence-based Practice
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.
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
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
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.
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
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
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
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, &
community mobility (Lemoncello, Sohlberg, & Fickas, 2010), and others. OT is able to address
memory. Several studies reviewed in a systematic review by Radomski et al. (2016) found that
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
strategy instruction” (Radomski, et al., 2016). Boelen, Spikman, and Fasotti (2011) found that
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
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
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
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-
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
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
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
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
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
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
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,
Summary
Learning Services is “founded on the belief that therapies should focus on the
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
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
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
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
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
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.
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
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.).
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
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
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
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.
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
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
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
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
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
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
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
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).
Goal 1. To improve the quality of life and independence of the residents at Learning Services
Objective 1. Within 6 months, 80% of the residents at Learning Services will increase
Objective 2. Within 6 months, 80% of the residents at Learning Services in improve their
Goal 2. To improve the staffs knowledge of traumatic brain injuries, and a therapeutic approach
Objective 1. Within 6 months, 80% of staff will independently implement the hierarchy
Objective 2. Within 6 months, 80% of staff will follow a home program provided by the
occupational therapist.
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.
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
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
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.
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
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
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
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
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.
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
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
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
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
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
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
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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?
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 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).
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
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
Goal 1:
Distal Outcome -2 -1 0 +1 +2
(Baseline) (Goal)
Much Less Less Expected Better Much Better
Level
(Target
Behavior)
2) 1) 1)
2) 2)
3) 3)
LEARNING SERVICES OCCUPATIONAL THERAPY PROGRAM 42
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?