PERSPECTIVES
Clinical Focus
Clinical Practice Recommendations for
Improving Life Participation for People
With Aphasia in Long-Term Care
Jamie H. Aziosa and Jack S. Damicob
Purpose: The purpose of this clinical focus article is to
present an overview of the Life Participation Approach to
Aphasia as it relates to issues in long-term care (LTC) and
provide practical recommendations for implementing the
approach in this setting. The Framework for Living With
Aphasia is used as a guide to (a) highlight specific challenges
to life participation for residents with aphasia in LTC and
(b) propose clinical tools that might help clinicians move
through the therapeutic process when implementing the Life
Participation Approach to Aphasia.
M
uch of the early research in aphasia was driven
by the idea that all therapeutic activities should
be guided by impairment. Therefore, in tradi-
tional approaches, aphasia was primarily seen from a dis-
ability standpoint with the foremost goal of treatment being
physiological recovery of function. Most of the work pub-
lished during this time was devoted to improving language
at a segmented level by maximizing correct responses by
a person with aphasia (e.g., Porch, 1967; Schuell, Jenkins,
& Jimenez-Pabon, 1964). This idea is still germane to the
medical model of disability and widely used today. As such,
it is not unusual for aphasia therapy to have a primary fo-
cus on improving deficits in the neurological system
with a goal of maximum restoration of linguistic function.
Although this approach is well intentioned and attrac-
tive, it can be misleading, as it operates from an assumption
that recovery requires a focus on “fixing” the impairment.
a clinical tools that might help clinicians move through the
Department of Speech and Hearing Sciences, Lamar University,
Beaumont, TX
b
Department of Speech, Language, and Hearing Sciences, University
of Colorado Boulder
Correspondence to Jamie H. Azios: jamie.azios@lamar.edu
Editor: Peter Meulenbroek
Received October 4, 2019
Accepted October 12, 2019
https://doi.org/10.1044/2019_PERSP-19-00136
Publisher Note: This article is part of the Forum: Directions and
Approaches to Aphasia Inspired by Life Participation Approach to
Aphasia Values.
384 Perspectives of the ASHA Special Interest Groups • Vol. 5 • 384–396 • April 2020 • Copyright © 2020 American Speech-Language-Hearing Association
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SIG 2
Recommendations: Clinicians in LTC facilities have the
responsibility of delivering services that have a positive
impact on communication, social relationships, emotional
health, and quality of life. Clinical tools and approaches
most appropriate for LTC settings are identified that help
to address these goals. Approaches are discussed across
several stages representing the therapeutic process, which
is ultimately aimed at moving a resident toward recovery
and increased independence. Case demonstrations are
provided to illustrate approaches.
Within the past few decades, many researchers and clinicians
have challenged this notion. This has resulted in a movement
away from a focus on language deficits intrinsic to a per-
son with aphasia and toward a discovery of communica-
tion competence and avenues for support (e.g., Ferguson,
1996; Simmons-Mackie & Damico, 1996a). This trend,
coupled with external influences by disability rights activ-
ists and a curtailment of funding for services, prompted the
creation of a philosophy of service delivery that better met
the needs of people impacted by aphasia, dubbed the Life
Participation Approach to Aphasia (LPAA; LPAA Project
Group, 2001).
The purpose of this clinical focus article is to high-
light the importance of LPAA in long-term care (LTC)
facilities and equip clinicians with practical recommenda-
tions for implementing LPAA in this setting. We use the
Framework for Living With Aphasia (A-FROM) as a
guide to (a) highlight specific challenges to life participa-
tion for residents with aphasia in LTC and (b) propose
therapeutic process when implementing LPAA. At the
conclusion of the clinical focus article, we provide two
case study demonstrations of LPAA based on the first
author’s clinical and research experiences to illustrate this
process in LTC.
Disclosures
Financial: Jamie H. Azios has no relevant financial interests to disclose. Jack S.
Damico has no relevant financial interests to disclose.
Nonfinancial: Jamie H. Azios has no relevant nonfinancial interests to disclose.
Jack S. Damico has no relevant nonfinancial interests to disclose.

LPAA
The LPAA is a philosophy rather than a specific treat-
ment approach and is based on many of the same values
and beliefs of social or pragmatic approaches to aphasia
(Simmons-Mackie, 2008). In LPAA, there is an unmitigated
emphasis on goals related to life participation and social
relationships regardless of a change in language function.
While a clinician implementing LPAA may work on improv-
ing or compensating for impairment within a relevant life
activity, equally important is targeting any barrier to life
participation. This is true even if the activity is not directly
related to communication (LPAA Project Group, 2001).
For example, a clinician may help a person with aphasia
work toward a goal of participating in a weekly poker night
with friends, joining a bible study, or hosting a family
gathering by training communication partners or making
the environment more “aphasia friendly” (Howe, Worrall,
& Hickson, 2004).
LPAA aligns with the desires of people with aphasia
and their family members. People with aphasia and their
family members have discussed the importance of outcomes
related to life participation, prioritizing goals related to
maintaining social networks and increasing independence
in various life roles and activities (Wallace et al., 2017).
Living a successful life after aphasia has been directly linked
to resuming activities from prestroke life, adapting activities
to increase participation, and developing new hobbies and
interests (Brown, Worrall, Davidson, & Howe, 2012).
While there is value in implementing LPAA across
the entire life span of a person with aphasia, including
acute stages, it may be even more beneficial in later stages
of recovery when aphasia is deemed chronic. The goals of
people with aphasia tend to change over time, with social
and relationship goals (e.g., conversing with friends, attend-
ing social outings) surfacing once the rehabilitation period
has ended (Worrall et al., 2010). Many individuals with
stroke-related aphasia may return home at this point, but
due to shortened hospital stays and changes to reimburse-
ment, an increasing number of stroke survivors do not.
In fact, approximately one in five people discharged from
a hospital after stroke is now entering LTC facilities for
further care (Nguyen et al., 2015). This estimate may be
higher for those with stroke-related aphasia since language
impairment has been recognized as a predictive factor for
institutionalization (González-Fernández, Christian, Davis,
& Hillis, 2013).
LPAA in a Conceptual Framework
It is often helpful to organize approaches and tech-
niques congruent with a particular philosophy within a
conceptual framework. Doing so can help guide clinicians
in creating client-centered goals and selecting useful, appro-
priate assessments and interventions that target the wants
and needs of the people receiving services. We have chosen
to use the A-FROM for our purposes here since it was
built upon value-based approaches within our field, such
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SIG 2 Neurogenic Communication Disorders
as LPAA and social models of disability (Kagan et al.,
2008).
The A-FROM was primarily based on the World
Health Organization’s International Classification of Func-
tioning, Disability and Health (World Health Organization,
2001), a biopsychosocial model of disability that defines
health in terms of physical, psychological, and social well-
being. While the International Classification of Function-
ing, Disability and Health is a broad measure applicable to
functioning and disability in various health conditions, the
A-FROM is specific to “living with aphasia” (Kagan et al.,
2008, p. 265) and the various internal and external factors
that might contribute to the degree of disability experienced
as the result of a condition. In the A-FROM, life with
aphasia is defined as the interaction of four major domains:
aphasia severity, communication and language environment,
participation in life situations, and personal factors includ-
ing identity and affective responses (see Figure 1). Aphasia
severity refers to the degree of impairment across linguistic
processing, including comprehension, expression, reading,
and writing. Communication and language environment
refers to the physical or social environment in which a per-
son lives and includes the actions and attitudes of others.
Participation in life situations encompasses the day-to-day
activities of people with aphasia and the roles, responsibili-
ties, and relationships manifested in these activities. Com-
munication and conversation are critical components of
this domain. Finally, the personal factors domain includes
how a person with aphasia may view themselves (i.e., iden-
tity) and any attitudes and feelings associated with aphasia.
Aphasia assessment and intervention in LTC may occur
across the entire A-FROM schematic. However, the envi-
ronment, participation in life situations, and personal iden-
tity may be the most critical domains for clinicians working
in LTC facilities as institutionalization often comes with
significant, distinct challenges associated with these categories.
Aphasia in LTC
Most LTC facilities are considered what Goffman
(1961) terms “total institutions.” Total institutions are unique
establishments because they function as both a place of res-
idence and a place of work where two sets of people (i.e.,
workers and residents) often have divergent sets of values
for existing in the same space. Inhabitants of total institu-
tions are separated from the outside social world and live a
relatively enclosed life. All of life participation occurs within
the confines of the facility, and there are minimal oppor-
tunities for engaging in activities in the outside world.
For persons with aphasia in LTC facilities, the facility “is”
home. Therefore, LTC facilities are likely one of the most
important health care contexts for implementing LPAA
and examining outcomes related to life participation.
Due to the complex nature of an environment with
two separate (and potentially conflicting) agendas, there
are many barriers to successful life participation in LTC.
In terms of the communication and language environment,
the physical makeup of a facility (e.g., physical layout,
385
SIG 2 Neurogenic Communication Disorders
Figure 1. The Framework for Living With Aphasia. Reprinted with permission from Aphasia Intitute.
acoustics, shared spaces) has been noted to negatively in-
fluence opportunities for social interaction (van Dijck-
Heinen, Wouters, Janssen, & van Hoof, 2014). Many staff
members lack the skills required to effectively support
residents with specific communicative needs, leading to com-
munication breakdowns (Bryan, Axelrod, Maxim, Bell, &
Jordan, 2002). Additionally, there is considerable staff turn-
over, impacting the ability for nurse assistants to become
familiar with individual interests and practice communica-
tion strategies (Long, Azios, & Richings, 2019; Page &
Rowles, 2016). Two studies have explicitly focused on real-
time interactions between nursing staff in LTC and persons
with aphasia. Azios, Damico, and Roussel (2018) found
that staff members in some facilities tend to prioritize phys-
ical needs over interactional needs, unintentionally deem-
phasizing communication for social purposes and meaningful
relationships. Similarly, Saldert, Bartonek-Åhman, and
Bloch (2018) discuss that, while nurses do engage in some
personal, psychosocial aspects of talk during routine care
activities, the main proportion of interaction (78%–90% of
time spent) includes talk central or related to the task at
hand.
Participation in daily life activities appears especially
limited for residents in LTC facilities. Several researchers
have discussed a lack of activity and stimulation in facili-
ties, leading to boredom and agitation for persons with
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dementia-producing conditions (e.g., Moyle et al., 2011).
For persons with aphasia in LTC facilities, opportunities
to engage in residential activities are even more difficult
due to the inappropriate and inaccessible nature of activi-
ties. In their observations of natural interactions in LTC
facilities, Azios et al. (2018) found that recreational activi-
ties chosen by facilities were not representative of age, cog-
nitive and communicative abilities, desires, or individual
strengths.
Increasing life participation in LTC can also be diffi-
cult due to personal factors such as identity and attitudes
related to aphasia. While there is an increased interest in
providing person-centered care in various facets of health
care, the act of entering an LTC facility can be viewed as a
terminal stage of life and promote the belief that an indi-
vidual’s personhood and life story are ending (Villar &
Serrat, 2017). Unfortunately for people with aphasia in LTC
institutions, depersonalization can happen quickly. Personal
histories of persons with aphasia in LTC facilities are often
lost due to the individual’s language impairment, and staff
members know little about residents with aphasia except for
the most basic information (Parr, 2007). Additionally,
people with aphasia in LTC settings have described feelings
of worry, frustration, and sadness as a result of aphasia
and hopelessness for improving communication abilities
(Hartwell, 2015).

Organizational Culture and the Role of the
Speech-Language Pathologist
Organizational culture in LTC plays an important
role in mitigating barriers related to life participation. Orga-
nizational culture refers to the shared belief systems, values,
and expectations that drive how people behave and com-
municate within an institution (Hemmelgarn, Glisson, &
James, 2006). There are several types of organizational
cultures in health care, but in LTC facilities, most types
are classified under two broad models of care: traditional
and resident centered. Traditional models of care employ
more authoritative and hierarchical practices where proce-
dures for care are rigid, predictable, and organized by those
who own or manage the facility (Brownie & Nancarrow,
2013). Contrastingly, resident-centered models of care pro-
mote a collaborative environment and shared decision
making to increase the independence of residents. Facilities
that implement resident-centered care are most interested
in putting a resident’s well-being above all other priorities,
fostering close and intimate relationships, and encouraging
engagement in personally meaningful activities (Thomas &
Johnson, 2003). Several studies have pointed to improved
resident outcomes in terms of quality of life, safety, health-
related measures (e.g., presence of infection), and engage-
ment in activities when LTC facilities implement resident-
centered care (for a review, see Shier, Khodyakov, Cohen,
Zimmerman, & Saliba, 2014).
Organizational culture impacts the behaviors and ac-
tions of professionals working within the setting. Speech-
language pathologists (SLPs) have an important role in
providing best practices in LTC facilities but often face
challenges related to organizational culture. SLPs have re-
ported that facilities have unrealistic expectations for pro-
ductivity standards and that they face ongoing ethical
dilemmas regarding various aspects of clinical decision mak-
ing (Cutter & Polovoy, 2014). A recent survey of SLPs
working in LTC facilities found that SLPs’ perceptions of
organizational culture impacted decisions to evaluate a
resident for language disorders (Douglas, 2016). Results
from the same study indicated that leadership within the
facility prohibited the majority of responding SLPs to im-
plement group therapy, a finding that is incongruous with
the large evidence base for this approach (e.g., Elman &
Bernstein-Ellis, 1999).
Despite these problems, SLPs have the responsibility
of delivering services that will have a positive impact on
communication, social relationships, emotional health, and
quality of life. While complete culture change in LTC is
complex and likely a lofty goal, clinicians can begin to ad-
vocate for change by practicing intellectual and behavioral
flexibility, developing personal relationships with staff
members and emphasizing their achievements, understanding
how to manage conflicts, and identifying facilitators and
barriers across policies and systems (Douglas & Hickey,
2015). When working directly with people with aphasia,
many of the foci and objectives of resident-centered care are
directly in line with those of the LPAA. For example, both
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SIG 2 Neurogenic Communication Disorders
philosophies prioritize psychosocial outcomes and engage-
ment in personally relevant life activities. Also, both models
encourage autonomy and operate under the assumption
that consumers can and should make their own decisions
about their needs and goals. See Figure 2 for additional
features of resident-centered care analogous to the LPAA.
By implementing LPAA in LTC, SLPs can be at the fore-
front of culture change and serve as a model for promoting
resident-centered care within the setting.
Practice Recommendations for Promoting
LPAA in LTC
In most LTC facilities, residents are identified for
therapy services upon admission. In these cases, the SLP
has little prior knowledge of the resident’s medical or social
history and will begin a data-gathering process that will
help to establish a communication diagnosis and severity,
describe communicative function across tasks and environ-
ments, and formulate an appropriate rehabilitation plan.
Other times, residents may be living in a facility for several
months to years before they are identified for services. The
process of identifying residents who may need services is
unique to each facility, but most facilities employ routine
screening to assess for any functional changes that may
have occurred over a set period of time. Here, the clinician
may have more or less familiarity with the resident at the
start of the assessment process, but residents typically have
a medical diagnosis (e.g., stroke) and communication
diagnosis (e.g., aphasia) prior to assessment. Regardless of
the source of referral, assessment and intervention in LTC
should follow a set of processes or stages aimed at moving a
resident toward recovery and increased independence.
Worrall, Sherratt, and Papathanasiou (2017) suggest the
following five steps: (a) information gathering and sharing,
(b) collaborative goal setting, (c) pretherapy assessment,
(d) therapy, and (e) reassessment. Steps are cyclical, and it
is customary for SLPs to revisit steps throughout the course
of therapy. Each step is outlined below with a description
of procedures most appropriate for promoting LPAA in
LTC. Examples of tools used during assessment stages (i.e.,
first three steps) are listed in Table 1. Please note this is
not an exhaustive list but are suggested tools deemed most
appropriate for clinicians electing to implement LPAA in
LTC facilities.
Step 1: Information Gathering and Sharing
In the first stage, clinicians are interested in gathering
information about a resident’s health condition and medi-
cal history as well as obtaining initial information across
all domains of the A-FROM. For the purposes of LPAA,
the communication environment, participation in day-to-day
activities, and personal identity domains are particularly
revealing and can begin to inform the clinician about the
degree to which aphasia impacts life participation. Broad,
self-report tools that capture information across multiple
domains may be most beneficial at this stage so the SLP
387
SIG 2 Neurogenic Communication Disorders
Figure 2. Corresponding features of Life Participation Approach to Aphasia and Resident-Centered Care.
can begin to understand strengths and barriers across activi-
ties and contexts. Two examples are described below and
include semistructured interviewing and the Assessment for
Living With Aphasia (ALA; Kagan et al., 2011). The SLP
should make every attempt to gain information from the
perspective of the person with aphasia but may also need
to rely on family members or care providers in this setting,
depending on severity of aphasia, presence of comorbidities
(e.g., hearing loss), and degree of isolation.
Ethnographic or semistructured interviewing of people
with aphasia and family members can help clinicians better
understand personal viewpoints about aphasia and its im-
pact on life participation (Simmons-Mackie & Damico,
1996b). Questions are usually broad and open-ended, such
as “Tell me a little about your aphasia” or “Tell me what
a typical day looks like for you,” prompting people with
aphasia to share their story (Worrall et al., 2017). The clini-
cian can then use follow-up questions to probe deeper into
challenges associated with specific life experiences or activi-
ties (e.g., getting dressed, conversing with staff and other
residents). See Westby (1990) for a detailed explanation of
the process of ethnographic interviewing.
A more formal assessment procedure that may be
beneficial for persons with more severe aphasia or those
reluctant to share experiences includes the ALA. The
ALA is a pictographic, self-report measure based on the
A-FROM. It was created with the input of important stake-
holders (i.e., people with aphasia, family members) and
has strong psychometric properties (Simmons-Mackie et al.,
2014). The ALA uses a conversational context but helps to
support expression and comprehension through picto-
graphic metaphors. For example, one of the most revealing
questions in the ALA includes “The Wall” question, which
can be used in conjunction with semistructured interviews
to gain perspectives about a specific life activity (Baier,
Hoepner, & Sather, 2018). The question uses a picture of a
wall with the word “aphasia” and a man at various stages
of the wall. There is a scale at the bottom of the picture
ranging from “big problem” to “no problem,” with the man
standing away from the wall, beginning to climb over it, or
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stepping to the other side. People with aphasia are encour-
aged to use the picture to help describe what “living with
aphasia” means to them.
Step 2: Collaborative Goal Setting
The next step in the assessment process includes de-
ciding what is most important to target for therapy. Most
people with stroke-induced aphasia are able to express
their own goals for rehabilitation but are often excluded
from the goal-setting process (Berg, Askim, Balandin,
Armstrong, & Rise, 2017). Since LPAA is “consumer
driven” (LPAA Project Group, 2001, p. 236), it shares
many values with person-centered care, including the philos-
ophy that the person with aphasia is the expert in their
own condition and that decision making about the thera-
peutic process should be collaborative (Hughes, Bamford,
& May, 2008). Thus, to implement LPAA in LTC, SLPs
must involve the resident with aphasia when creating goals.
Based on the previous step, clinicians should have
a few ideas about the major concerns of the resident with
aphasia. The important part of this stage is to convert
concerns into written objectives (Worrall et al., 2017). For
people with limited expression, the SLP may use instru-
ments with picture symbols such as the Life Interests and
Values Cards (Haley, Womack, Helm-Estabrooks, Caignon,
& McCulloch, 2010) or Talking Mats to help support the
selection of goals most important to the resident. Both tools
have been used successfully for collaborative goal setting
in people with varying degrees of aphasia (e.g., Haley,
Womack, Harmon, & Williams, 2015; Murphy & Boa, 2012).
Isaksen (2018) also discusses clinicians attempting collabo-
rative goal setting through supported conversation tech-
niques (Kagan, 1998) or self-made aphasia-friendly initiatives
to help support the interaction (e.g., smiley scales).
There are a few frameworks that can help guide clini-
cians in collaborative goal setting. Hersh, Worrall, Howe,
Sherratt, and Davidson (2012) suggest a process where clini-
cians establish SMARTER goals, ones that are Shared,
Monitored, Accessible, Relevant, Transparent, Evolving,
 SIG 2 Neurogenic Communication Disorders

Table 1. Tools for assessment of life participation in long-term care facilities.

Tool Information source A-FROM domain(s)

Ethnographic interviewing Self-report Environment

Participation
Personal identity
Assessment for Living With Aphasia Self-report Environment
Participation
Personal identity
Communicative Profiling System Self-report and clinician rating Environment
Participation
Personal identity
Life Interests and Values Cards Self-report Environment
Participation
Personal identity
FOURC model Self-report Environment
Participation
Personal identity
ASHA-FACS Clinician rating Participation
Communication Effectiveness Index Caregiver rating Participation
Measure of Skill in Supported Conversation Clinician rating Environment
Measure of Participation in Conversation Clinician rating Participation
MECQ-LTC Clinician rating Environment
Participation
CADL-3 Clinician rating Participation
Comprehensive Aphasia Test–Disability and Impact Questionnaire Self-report Environment
Participation
Personal identity
SAQOL-39 Self-report Participation
Personal identity
Burden of Stroke Scale Self-report Participation
Personal identity
Communication Confidence Rating Scale for Aphasia Self-report Participation
Personal identity

Note. Ethnographic interviewing from Westby (1990), Assessment for Living With Aphasia from Kagan et al. (2011), Communicative Profiling
System from Simmons-Mackie and Damico (1996b), Life Interests and Values Cards from Haley et al. (2010), FOURC model from Haley et al.
(2019), American Speech-Language-Hearing Association Functional Assessment of Communication Skills (ASHA-FACS) from Frattali et al.
(2017), Communicative Effectiveness Index from Lomas et al. (1989), Measure of Skill in Supported Conversation and Measure of Participation
in Conversation from Kagan et al. (2004), Montreal Evaluation of Communication Questionnaire for Use in Long-Term Care (MECQ-LTC) from
Le Dorze et al. (2000), Communication Activities of Daily Living–Third Edition (CADL-3) from Holland et al. (2018), Comprehensive Aphasia
Test–Disability and Impact Questionnaire from Swinburn et al. (2004), Stroke and Aphasia Quality of Life Scale (SAQOL) from Hilari et al. (2009),
Burden of Stroke Scale from Doyle et al. (2004), and Communication Confidence Rating Scale for Aphasia from Babbitt et al. (2011). A-FROM =
Framework for Living With Aphasia.

and Relationship centered. Haley, Cunningham, Barry, and
de Riesthal (2019) describe the FOURC model, a tool to
help clinicians work with clients to identify meaningful goals
across four intervention prongs: skills and abilities, inten-
tional strategies, environmental supports, and motivation
and confidence. The FOURC model was developed as an
extension of the A-FROM, and each prong correlates with
the A-FROM domains associated with living with aphasia.
Step 3: Pretherapy Assessment
Now that the clinician has a better understanding of
the goals of the person with aphasia, some measure of per-
formance should be gathered as a precursor or baseline to
therapy. Tasks during pretherapy assessment should be in-
dividualized, and tools should capture abilities and barriers
related to life participation in a particular domain. For
example, if information gathering and collaborative goal
setting reveal that a resident with aphasia would like to
improve the ability to converse with other residents during
a meal, then the assessment tool or procedure should
reveal a measure of conversation participation at meals.
Assessments at this stage can be self-report or rated by
the clinician, but a combination of both measures is
preferred.
SLPs in LTC have a great responsibility in ensuring
that the communication and language environment of the
facility is accessible. If a resident wants to improve inde-
pendence in communicating health care decisions to staff
members (e.g., taking medication, doctor visits), the SLP
must use an assessment tool that reveals barriers in the com-
munication environment when these exchanges occur. The
most accessible way to collect this type of data in LTC is
through direct observation. While this method can help a
clinician obtain detailed, resident-specific information, the
quality of the data often relies on the expertise of the ob-
server. Inexperienced observers in LTC may want to use
published tools to help guide observations such as the

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SIG 2 Neurogenic Communication Disorders
Measure of Skill in Providing Supported Conversation for
Adults With Aphasia (MSC; Kagan et al., 2004) or the Prag-
matic Protocol (Prutting & Kirchner, 1987). Le Dorze et al.
(2000) developed the Montreal Evaluation of Communica-
tion Questionnaire for Use in Long-Term Care, which is
designed to assess the frequency of communication acts of
residents in LTC and staff members’ degree of effort required
for efficient communication.
Securing independence in daily life activities is a com-
mon goal for residents with aphasia in LTC. For this rea-
son, it is often helpful to select a measure of participation
in conversation (MPC) or other language activity (e.g.,
reading the newspaper) prior to initiating treatment. For
residents with greater levels of independence, the Communi-
cation Activities of Daily Living–Third Edition (Holland,
Fromm, & Wozniak, 2018) can be used to assess functional
communication abilities across a wide array of activities.
If a resident with aphasia is interested in developing more
social relationships, clinicians may complete a social net-
work map (see Simmons-Mackie & Damico, 2001) that de-
tails the quantity, type, and closeness of social contacts.
Regardless of severity or level of dependence, a measure of
communicative ability in conversation should preface inter-
ventions working toward increasing compensatory strate-
gies across communication contexts. While most clinicians
lack the time and skills required to complete detailed con-
versation analysis, the presence and frequency of facilita-
tive behaviors (e.g., writing, gesturing, circumlocution) can
be tallied during a sample of conversation and used to in-
form treatment. A few scales have been developed to cap-
ture interactional and transactional aspects of conversation
such as the MPC (Kagan et al., 2004). Self-report measures
of participation in life situations have also been developed
and validated including the Communicative Effectiveness
Index (Lomas et al., 1989). However, SLPs must recognize
many of these scales were not specifically developed for
persons with aphasia in LTC, and some items refer to activi-
ties not representative of this setting.
If the shared goal is to increase personal identity and
positive emotions postaphasia, clinicians may need to
gather measures that assess affective responses to aphasia.
This may be done through self-report measures of particu-
lar feelings such as confidence (Communication Confidence
Rating Scale for Aphasia; Babbitt, Heinemann, Semik, &
Cherney, 2011). Alternatively, clinicians may select self-report
measures that assess multiple dimensions of health care–
related quality of life but include sections on positive and
negative feelings after aphasia (e.g., Burden of Stroke Scale
[Doyle et al., 2004] and Stroke and Aphasia Quality of
Life Scale [Hilari et al., 2009]). Since personal narratives
serve as an important part of identity formation (Bruner,
1987), baseline data on the ability to recount life experi-
ences before and after institutionalization and aphasia
may be beneficial. Olness, Gyger, and Thomas (2012)
outline measures of referential and evaluative function that
clinicians may want to assess in personal narratives, includ-
ing references to activities, order of events, key background
information, and evaluative devices. The authors provide
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an appendix that includes a checklist of criterion-referenced
measures and behavioral observations.
Step 4: Therapy
Intervention in line with the LPAA may address any
domain of the A-FROM, including impairment-focused
approaches. However, due to distinct barriers and chal-
lenges for people with aphasia in LTC that are associated
with the communication environment, participation in daily
life activities, and personal identity, therapies addressing
these domains may be most valuable. As with LPAA in
any setting, the focus of intervention can be on both personal
(internal) and environmental (external) factors through
any stage of recovery (LPAA Project Group, 2001).
Approaches targeting the communication and lan-
guage environment may be more heavily oriented toward
external factors. Clinicians may work toward making sign-
age, notices, and other written information in the LTC
facility aphasia friendly by adding pictographs, simplifying
syntax, adding bullets, or bolding and increasing the font
(Rose, Worrall, Hickson, & Hoffmann 2011). For exam-
ple, an SLP may work with a resident to make menus
more aphasia friendly to increase independence in selecting
foods for meals. Perhaps the most important type of inter-
vention in LTC involves training communication partners.
Specific techniques in LTC includes the use of individual-
ized communication plans (e.g., Généreux et al., 2004).
Page and Rowles (2016) describe a communication plan as
a one-page document specific to each resident that details
(a) strategies that staff can use to increase communication
accessibility, (b) specific behaviors that the resident uses
to communicate, and (c) a resident’s likes and dislikes.
Simmons-Mackie et al. (2007) describe a training given to
multiple staff members of an LTC facility that included
information about aphasia and hands-on experience using
supported conversation techniques. Hickey, Bourgeois, and
Olswang (2004) trained volunteers on how to converse with
residents with aphasia through a multimodality communi-
cation program. Results from these studies and others
indicate that a variety of partners can be trained to commu-
nicate with residents with aphasia and partner training is
an important avenue for addressing the communication
and language environment (Simmons-Mackie, Raymer, &
Cherney, 2016).
Improving participation in daily life activities may
involve therapy approaches that target both internal and
external factors. One common way to improve communi-
cation abilities across multiple daily life activities is to
improve a resident’s facilitative strategy use in conversation.
In LTC, this typically involves bolstering multimodal
communication strategies (e.g., writing, pointing, gesturing)
and other self-cueing strategies (e.g., circumlocution, spell-
ing). Conversation therapy can be used to increase aware-
ness of strategies that are most facilitative and reduce
behaviors that act as a barrier to getting a message across
(Damico et al., 2015). Many residents with and without
aphasia discuss reading as an enjoyed activity. In an LPAA

approach, clinicians may focus on providing the resident
access to an audio book version of a text or practice com-
prehension strategies during authentic reading tasks (Lynch,
Damico, Abendroth, & Nelson, 2013). Finally, group
therapy has a long-standing history and evidence base for
improving communication and linguistic abilities (e.g.,
Elman & Berstein-Ellis, 1999), but it may also be imple-
mented in LTC facilities to encourage the development of
relationships among residents and establish a sense of
community. Under the new patient-driven payment model,
SLPs can continue to utilize group therapy for residents;
however, minutes for group therapy cannot exceed more
than 25% of the total treatment time over the course of the
rehabilitation period.
To address personal factors, clinicians may consider
creating stroke support groups within the facility. It may
be difficult in small facilities to begin support groups re-
stricted to persons with aphasia. In the first author’s expe-
rience of beginning a support group in LTC, it is helpful to
include all stroke survivors and discuss differences and
similarities between communicative and physical conse-
quences of stroke. Defining terms such as “aphasia” and sup-
porting stroke survivors’ ability to share their personal
journey among like-minded people can lead to positive and
empowering perspectives (Tregea & Brown, 2013). Counsel-
ing techniques such as those suggested in positive psychol-
ogy can also be used to help build resilience and hope
(Holland & Nelson, 2020). Recently, there has been a move-
ment toward the use of personal narratives as a medium
for addressing identity challenges. Strong, Lagerwey, and
Shadden (2018) discuss a protocol for intervention designed
to help a person with aphasia construct a personal narra-
tive about life with aphasia. During the intervention, the
SLP works with a person with aphasia to co-construct their
life story before and after aphasia through whatever com-
munication means possible. Artifacts such as photographs
are used to help clients formulate stories, and multimodal
communication strategies are explored and practiced for
storytelling. Results of the study indicate that the process
of co-constructing the story helps to support a positive view
of identity and increase hope and confidence in communi-
cation skills.
Step 5: Reassessment
After goals have been targeted through an interven-
tion approach, clinicians should reassess the resident’s abil-
ities. This can be done through the same techniques used
in pretherapy assessment or can represent an overall mea-
surement of the resident’s progress toward goals. In LTC,
most Medicare intermediaries require recertification every
30 days, which may be an opportune time for reassessment.
SLPs working in LTC should discuss findings from the
reassessment with the resident, family members, and routine
care providers and work collaboratively toward goal refor-
mation or discharge. The decision to discharge a resident
with chronic aphasia is often difficult due to set time limits
to rehabilitation programs, inability to review discharge
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SIG 2 Neurogenic Communication Disorders
decisions, and a lack of “objective” improvement (Hersh,
2009). In LTC, the SLP will be visible in the facility after
the resident has been discharged from speech services, caus-
ing even more ambiguity about the discharge process. For
these reasons, SLPs in LTC must take great care in develop-
ing strategies for discharge that underscore best practice
and LPAA values. As Simmons-Mackie et al. (2017) sug-
gest in the 10 best practices of effective aphasia therapists,
SLPs should not discharge clients from services without
some means of communicative needs and desires (e.g., using
multimodal communication, visual supports, trained part-
ners). Hersh (2003) discusses how clinicians “wean” clients
from services as part of the discharge process. She suggests
that clinicians use beneficial strategies for negotiation
purposes, including talking about discharge in advance and
discussing goals with a focus on discharge from the begin-
ning. Also, clinicians use encouraging talk when discharge
is near, which helps to boost client’s confidence and pre-
pares them for the path toward discharge. SLPs in LTC
should consider implementing these strategies when dis-
charge is imminent. There may also be future opportunities
to re-evaluate the need for speech therapy services for a
resident if there is a need or change in status.
Case Study Illustrations
To better illustrate the process of implementing LPAA
in LTC, we present two case studies of long-term residents
with chronic aphasia. Each study is based on the first
author’s clinical experiences when she was employed as a
staff member in LTC. Information on demographics, char-
acteristics of aphasia, and outcomes presented in the cases
was also obtained from facility records as a part of the
study of Hartwell (2015). We have assigned pseudonyms for
each case and have altered some of the details for confiden-
tiality and explanatory purposes. While we no longer have
access to standard scores on assessment batteries for the
cases, we will provide descriptive data on characteristics and
severity of aphasia, social and medical histories, and overall
communicative functioning so readers can employ case-to-
case transfer for generalization purposes (Firestone, 1993).
Case 1: “Norman”
Norman was a 72-year-old man who was admitted
to the LTC facility after experiencing a left hemisphere
stroke. His medical history was remarkable for a small, re-
mote right hemisphere stroke, arthritis, hypertension, and
atrial fibrillation. Prior to admission, Norman lived alone.
He was previously married but did not have any children.
Norman graduated high school and worked odd jobs until
he joined the military during World War II. When Norman
returned home from war, he moved back to his small
hometown. Norman’s hobbies included playing cards, so-
cializing with his friends, and working on cars. He fre-
quented bars and enjoyed nightlife. Norman got into an
altercation one night with a friend, and both parties sus-
tained injuries. The police were called, and Norman was
391
SIG 2 Neurogenic Communication Disorders
incarcerated for several years. He experienced his second
stroke approximately ten years after his release from prison
and was admitted to the LTC facility due to inability to
physically care for himself at home. Norman’s name ap-
peared on a routine screening form given to the SLP. The
SLP conducted a cursory review of his medical chart and
noted the diagnosis of stroke and aphasia and that he had
not received therapy since his initial 100 days in the facility
(approximately one year prior). The SLP visited Norman
and conducted a brief interview about his current activities
in the nursing home and how he felt about his ability to
communicate with others. Norman expressed that he felt
his language had deteriorated since his admission and that
he was no longer confident speaking to others.
At this point, the SLP decided to conduct a compre-
hensive assessment to begin to gather information across
the A-FROM domains. This stage began with a thorough
chart review and a short interview with Norman’s routine
nurse aide. The SLP employed ethnographic interviewing
as a self-report technique to better understand strengths
and barriers across the communicative environment, partici-
pation in daily life activities and social relationships, and
feelings associated with aphasia. The SLP also used this
time to assess auditory comprehension and verbal expres-
sion abilities within natural conversation, noting Norman’s
attempts to self-repair when he had a word-finding prob-
lem and any difficulties with understanding and following
conversation. Based on the first stage of the assessment,
Norman presented with mild aphasia characterized by
functional auditory comprehension in conversation, intact
syntax, and word-finding problems for low-frequency words
and proper nouns (especially the names of places). He often
used vague words such as “thing” or “there” as a substitute
for the word that was inaccessible and had difficulty with
pronoun reference. He paused often during conversation,
which often led to what he described as “speaking for”
behaviors by other residents and nurse aides (Croteau &
Le Dorze, 2006). Norman described negative emotions
associated with his aphasia. He admitted that he isolated
himself from others and could not list a single activity that
he participated in since he was admitted to the nursing
home. Even though Norman’s language difficulties were so
mild that many nurses did not recognize that he had apha-
sia, he felt very poorly about himself and did not have
confidence to participate in daily life activities.
The SLP used the next session for collaborative goal
setting. Since Norman’s aphasia was mild, he was able to
participate in selecting goals with a few supportive commu-
nication techniques such as keywording and drawing
(Kagan, 1998). The SLP used these tools to outline potential
ideas for goals and then facilitated a discussion about pri-
oritizing what was most important to address immediately.
It was clear from Norman’s responses that participation
in daily life activities, especially activities that would combat
his boredom and loneliness, were of most importance.
Through the discussion, Norman revealed that he wanted
to begin to read again to learn about different topics. He
had not read since his aphasia and institutionalization. He
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was not sure of his reading ability, but he stated that he
could read his menu during meals and he was able to recog-
nize and understand signage in the facility. The goal
would be to increase reading efficiency and comprehension
strategies to participate in reading activities for pleasure.
Pretherapy assessment included baselining reading
performance and comprehension across a variety of tasks.
First, probes were used from a standardized test battery to
identify comprehension at the single word, sentence, and
paragraph level. While Norman exhibited some delays, he
was able to read a sentence-level direction and follow the
command without any errors. He did make a few errors
when answering close-ended questions after reading exposi-
tory paragraphs. To assess functional reading abilities,
the SLP conducted an analysis of Norman’s oral reading,
making note of low-quality changes while reading that
affected the meaning of the text (e.g., omitting important
words, semantic paraphasias) and any compensatory strat-
egies that appeared to increase reading fluency (e.g., appro-
priate word substitution, rereading sections). The SLP
kept a simple tally of low-quality changes to the text and
compensatory strategies during a reading sample as an
objective baseline measure. A simple guide to miscue anal-
ysis with a template for tracking errors can be found on
the National Center on Intensive Intervention at the Amer-
ican Institutes for Research website.
Norman chose to read a book about a place he was
stationed for World War II. The SLP provided a few op-
tions that were at an appropriate reading level, and Norman
made the selection. The first step in therapy involved in-
creasing accessibility to external aids that would improve
reading efficiency and comprehension. This was done
through “reading ramps” (Elman & Bernstein-Ellis, 2006,
p. 33), which included the use of chapter summaries, vocab-
ulary lists, and an audiobook version of the text (Knollman-
Porter, Wallace, Hux, Brown, & Long, 2015). Norman
and the SLP worked together to try out these supports while
reading to select what supports worked best and at what
stages of reading. Next, the SLP and Norman engaged in
shared reading tasks that involved taking turns reading
aloud to practice efficiency and comprehension strategies.
Some strategies that Norman found most effective were
pacing or rereading of more complex words and sentences,
substitution using abbreviations or simpler words, and
skipping function words (e.g., the) to simplify grammatical
complexity (Lynch et al., 2013). The SLP modeled these
strategies during reading and also highlighted Norman’s
use of the strategies during sessions to increase awareness
of the timing and effectiveness of strategies.
At reassessment, the SLP completed another analysis
of Norman’s reading abilities by tabulating the number
of low-quality miscues and compensatory strategies used
during an authentic reading task. She also kept an inventory
of the quantity and types of books that Norman was now
able to read. After several weeks of intervention, Norman
became interested in reading books about incarceration,
being that he had been incarcerated and had received news
that a distant cousin was now in prison. He expressed a

new desire to work toward writing letters to his distant
cousin but was concerned with his writing abilities after
aphasia. The SLP and Norman revisited the first stages of
the therapy process and began working toward a new goal
of improving writing abilities to exchange simple letters
with his relative.
Case 2: “Celine”
Celine was a 59-year-old woman who was admitted
to the LTC facility after a left middle cerebral artery stroke
resulting in severe aphasia and apraxia. Celine was divorced
and had three adult children and two grandchildren. Prior
to her stroke, she lived alone and worked as a nanny. Her
friends and family described her as a vivacious woman who
enjoyed drinking coffee and talking with friends, going to
the beauty parlor, and listening to country music. Celine’s
medical history was remarkable for diabetes and hyperten-
sion. She was uninsured at the time of her stroke, so she
received little rehabilitative services in the weeks after her
stroke. She was discharged to the LTC facility at approxi-
mately three weeks postonset. Celine was enrolled in physi-
cal, occupational, and speech therapy when she entered
the nursing home, but sessions were only approved for
30 min, three times a week. She received impairment-focused
speech therapy that mostly targeted her severe apraxia
and was discharged approximately two months after admis-
sion. Since Celine had not made enough progress to care
for herself at home, she remained in the nursing home as a
long-term resident. One day, Celine was in her room visi-
bly frustrated and emotional. The SLP passed by her room,
noticed her crying, and entered her room to ask if she
needed assistance. Celine was pointing and gesturing but
was unable to communicate why she was upset or what
happened.
The SLP was new to the facility and did not know
Celine but immediately recognized she had severe aphasia
and was unable to communicate her needs and desires.
Since Celine had a limited payor source, the facility was
responsible for payment of all therapy services. The SLP
requested approval from the facility for assessment and
treatment and was granted 30-min sessions, five times a
week, for a 30-day period. The assessment process started
with gathering broad information across the A-FROM
domains. The SLP conducted a thorough chart review
and cursory interview with Celine’s nurse and nurse aide,
who both worked with Celine over the past few years
and shared detailed information about her abilities to com-
municate during routine care tasks. Celine’s aphasia and
apraxia were severe, and although her auditory compre-
hension appeared only mildly impaired at the conversational
level, her spontaneous expression was mostly limited to
“yes,” “no,” “and,” and “thank you.” Celine was unable
to participate in an ethnographic interview but was able to
complete most portions of the ALA. The ALA revealed
that Celine was dissatisfied with her life after aphasia. She
had few communication partners within or outside the
nursing home and engaged in few to no conversations.
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SIG 2 Neurogenic Communication Disorders
Based on Celine’s responses on the ALA and inter-
views with staff members, there were many barriers in the
communication and language environment and challenges
associated with participation in life activities (especially
conversation). The SLP used supported conversation tech-
niques, including keywording, drawing, close-ended ques-
tions, and pictographs from the Life Interests and Values
Cards for collaborative goal setting (Haley et al., 2010;
Kagan, 1998). The SLP provided broad, simple goals and
presented them to Celine with the supports. For example,
the SLP wrote “talking at lunch” and showed a pictograph
to Celine, and she responded with “yes” or “no” with
varying levels of repetition and emphasis. From this process,
it was apparent that Celine wanted to increase her ability
to contribute to conversations with the women that sat
with her each day for meals.
For pretherapy assessment, the SLP needed to better
understand the range of difficulties and strategies present
during Celine’s conversation and also what barriers were
present in the communication environment. Therefore, the
SLP needed a baseline for the communication and language
environment and a separate baseline for participation in
conversation. This began with two separate observations
across mealtimes, using the MSC to guide observations.
The MSC, MPC, and processes for determining scores can
be accessed for free on the Aphasia Institute website. All
three women that Celine ate with were older than her but
appeared more physically and cognitively independent than
other residents. It was clear that the women had similar
interests, backgrounds, and mutual acquaintances outside
the facility. Unfortunately, Celine was not included in
most of these conversations, and the women used unnatural
talk when speaking to her (e.g., increased loudness, un-
natural pauses, patronizing at times). They also tended to
talk over one another, multiple women speaking at the
same time, and would ask strings of questions to Celine
when she was uninvolved in conversation. The SLP used
the rating scale provided in the work of Kagan et al. (2004)
as the basis for objective goal formation. To baseline Celine’s
conversation abilities, the SLP engaged in a 10-min conver-
sation with Celine and took an inventory of multimodal
and verbal communication strategies used within the time
frame. While Celine could write and practiced writing as
“homework” given to her by the previous SLP, family,
and friends, she did not employ writing during conversation.
At times, she used pointing and gesturing and changes to
the frequency and intonation of “yes” and “no” during the
conversation, and she occasionally repeated the SLP’s turn
to signal agreement/disagreement or to request more infor-
mation on the topic. These strategies, while helpful, were
not used consistently or optimally during conversation, and
Celine remained mostly passive during the conversation.
For baselining and objective goal formulation, the SLP
used the rating scale provided in the work of Kagan et al.
and a simple frequency count of compensatory strategies in
conversation during the 10-min sample.
Therapy was initiated to target the two separate goals
for decreasing barriers in the communication environment
393
SIG 2 Neurogenic Communication Disorders
and increasing participation in conversation. Since the
SLP was able to conduct sessions five times a week, three
sessions were devoted to individualized conversation inter-
vention with Celine and two sessions were devoted to con-
versation partner training. The SLP approached the three
women at the facility and asked if they would be interested
in learning how to better communicate with Celine. Two
of the three agreed to learn supported conversation tech-
niques. They expressed that they understood that Celine
had a stroke but did not understand the word “aphasia” or
what it meant. It is important to note that these residents
were considered “high functioning” when compared to
other residents with various cognitive and psychological
disorder. They were institutionalized because they were
widowed and had various physical ailments that precluded
them from driving and living independently at home. The
SLP included both women and Celine in the sessions devoted
to partner training. Introductory sessions involved simple
explanations of aphasia and the strategies that Celine may
use to communicate. The residents were taught three basic
strategies: using yes/no questions, slowing rate by pausing in
between phrases, and acknowledging when Celine was
frustrated and unable to get her message across. Sessions
involved talking about the strategies, providing models, and
practicing the strategies with feedback. During the individ-
ual sessions with Celine, the SLP implemented a conversa-
tion intervention that worked toward increasing awareness
of facilitative strategy use (writing, iconic gesturing, verbal
repetition) through practice in authentic conversation, self-
evaluation, and feedback. See Damico et al. (2015) for a
complete description of the approach.
At the end of the 30 days, the LTC facility required
a reassessment. The SLP observed mealtimes using the
MSC to track the progress of Celine’s communication part-
ners and collected a conversation sample with frequency
counts of targeted compensatory strategies. While there
were slight improvements in strategy deployment for both
the partners and Celine, conversation during meals was not
completely accessible for Celine. Celine expressed that,
although she felt better about her relationship with the women,
she remained unhappy with her level of participation in
conversation. The SLP provided the facility with the objec-
tive data taken during the treatment period, requested ad-
ditional time to continue intervention, and was granted
another 30 days of treatment. The SLP continued the plan
of care and was required to discharge Celine after the
final 30 days. Prior to discharge, the SLP created a com-
munication plan for the two residents involved in partner
training and also nurse aides working with Celine. The plan
detailed effective partner strategies, Celine’s primary com-
pensatory strategies for getting a message across, and what
context the strategies appeared most beneficial. For exam-
ple, while writing was a strategy that Celine could use effec-
tively, she felt uncomfortable using it in more public
spaces or in group conversations. The discharge process
was difficult for Celine since she did not feel that she had
reached her desired level of performance in life participa-
tion. However, advance discussions and the creation of
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communication plans helped to decrease worry and other
negative emotions surrounding discharge.
Conclusions and Final Remarks
Residents with aphasia in LTC often experience sig-
nificant barriers associated with the communication and
language environment, participation in life situations in-
cluding conversation and the development of relationships,
and renegotiation of identity after aphasia. Implementing
the LPAA in these settings is critical in helping residents
improve social participation, reengagement in life after
aphasia, and overall quality of life. Published assessment and
intervention tools are appropriate for residents with aphasia
in LTC and can be used during the therapeutic process to
target meaningful, client-centered goals. While many chal-
lenges remain for SLPs in LTC, clinicians must recognize
that they have a critical role in advocating for residents
with aphasia to receive the best possible care and helping
to change the organizational culture in LTC. The LPAA
and A-FROM provide a framework for SLPs to begin to
shape the structure of assessment and intervention in this
setting and promote positive and lasting change for residents
with aphasia.
Acknowledgments
We would like to thank the staff members and residents that
we have had the pleasure of working with during our time in
long-term care facilities. These experiences continue to inspire us
in our work and have taught us important clinical lessons that we
hope to pass on to the next generation of clinicians in this setting.
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