Specialist services at OZC Andrew Bateman PhD MCSP.

Specialist services at

OZC

Andrew Bateman

PhD MCSP

Ian ‘personal construct’ outcomes Work hard and achieve 1 2 3 4 5 6 7 “GO OFF”, not things achieve Happy and making 1 2 3 4 5 6 7 A problem for others others happy Head injury as the main 1 2 3 4 5 6 7 One of the human thing in my life race – just like every- one else Feeling confident 1 2 3 4 5 6 7 Loss of confidence

Pre-Injury selfIdeal self Change in ‘present self’ from start – end programme

History

Centre founded by Prof Barbara Wilson, opened November 1996

Modelled on Adult Day Hospital, Phoenix Arizona & Oklahoma programme

Lifespan NHS Trust, Anglia & Oxford NHS Executive & MRC

National Service Influenced by work of Prigatano, Ben-Yishay & Christensen

Who was Oliver Zangwill ?

Professor of Experimental Psychology, Cambridge University, 1952 - 1982.

1940’s Edinburgh working with war injuries.

Major influence on British rehabilitation. First to apply neuropsychological

knowledge to rehabilitation.

Mission Statement

To provide high quality rehabilitation for the individual cognitive, social, emotional, vocational and physical needs of people with non-progressive brain injury

Oliver Zangw ill Centre Team

R e sea rch O T R e se arch F e llow

R e sea rch A ss is ta n t

D irec to r o f R e sea rch

C lin ica l S p ec ia lis t O T

S en io r I O T

T h era py A ss ista n t

H E A D III O T

S p ec ia listS A LT

S p ec ia list S A LT(B IR T )

L ea d S A LT

C lin ica l P sych o lo g ist C lin ica l P sych o lo g ist

P sych o lo gy A ss ista n t P sych o lo gy A ss ista n t

L e ad P sych o log ist

C o urse A d m in is tra to r R e sea rch A ss is ta n t

A d m in A ss ista n t N eu roP a ge

S u pp or t M an ag er

C lin ica l M an ag er

Andrew Bateman

Neuro Rehabilitation Clinical Lead

Jill Winegardner

Clinical Psychologist, (B8) P/T

Barbara Wilson

P/T (1/7)

Cat Ford

Clinical Psychologist

(B8A) F/T

(Clinical/Supervision 02 3/7)

Research 2/7 AIMS

CLAHRC

Research student at Uni.Cambridge

Jackie Galway

Clare Keohane

Head Specialist Speech & Language Therapist

(8A) P/T 3/7. Mon, Tues, Thurs

CCS, Stroke

E.C. & F

City & South, Huntingdon

Michelle Young

Support Manager

(B5) P/T 30hrs 5½ days

Leyla Prince

Specialist Speech & Language Therapist

(B7) F/T

Diana McCollum Specialist Speech

& Language Therapist

(B7)

Seconded manager of

paediatric team

(P/T 1/7) Mon - Weds

(2 Paed) 1/7 ozc clinicall

Fiona Ashworth

Clinical Psychologist

(B7) F/TEmma

Rehab Psychology Assistant

vol) Temp, F/T

Leah Bousie

Rehab Psychology Assistant

(B4) F/T

Chantel Williams

Rehab Psychology Assistant

(B4) F/T

Supervise all admin

Sharon McEwing

Personal/

Administration Assistant

(B3) F/T

Rachel Everett

Marketing & Courses

Administrator

(B3) P/T 20hrs

2x full days (Mon, Tues),

1x½ day (Weds)

Donna Moore

NeuroPage Administrator

(B2) P/T 15hrs

Full – Mon, Part Weds/FriBand 3 (?F/T)

(Amy Rideout)

(new student)

Psychology Research Assistant

OZ (F/T)

(Voluntary) 1/7CBU

Anna Piasceka

Psychology Research

Assistant OZ (F/T)

Gemma Hardy

Research Assistant

MRC-CBU (F/T)

Eve Greenfield

Research Occupation

al Therapist

MRC-CBU (P/T)

April – 4/7 Clinical/SPM

1/7 CLAHRC

3/7 Clinical/SPM

2/7 CLAHRC

TEMP

Helen Howe

Bank admin

P/T 12hrs

Am – Tues, Thurs, Fri

April

Sue Brentnall

Head Occupational Therapist

(B8A) P/T (5½ days 28)

Donna MalleyOccupational

Therapist Clinical Specialist

(B8A)

Band 7

Maria Martin Saez FT

Carolyne Threadgold

Rehabilitation Assistant (B4) P/T

4/7

Band 7 (vacant) F/T

Rachel Harrison

Occupational Therapist (B5) F/T

The Team

3 Clinical Psychologists 2.6 (w.t.e.) Occupational Therapists 1.6 (w.t.e.) Speech & Language

Therapists 3 Psychology/rehabilitation Assistants 1 Clinical Manager 4 Administrators Visiting Neuropsychiatrist (0.1 w.t.e) Access to Neurologist & Physiotherapy

Principles of rehabilitation approach Holistic approach Addresses cognitive, emotional and social

consequences of ABI Hierarchy of stages (engagement,

awareness, mastery, control, acceptance, identity)

Safe environment

5 activities of OZC

Assessment Rehabilitation Research Education NeuroPage service

+ neurorehab management for CCS

Assessment and Rehabilitation

Sources of Referrals

Private: Self-referral, relative, solicitor, insurance company.

NHS: G.P, NHS clinician, Consultant Weekly preliminary assessments Fortnightly detailed assessments 4 intakes per year for full programmes Referrals to Andrew Bateman, Clinical

Service Manager.

Referral criteria Adults with non-progressive acquired brain injury Medically stable - +/- 18 months post injury Not demonstrating severe disruptive behavioural

disorders or marked physical disability Capable of managing in community B&B or self-

catering accommodation. Require IDT for cognitive, psychological and

social issues restricting their participation in daily life

Client DemographicsGender

Female27%

Male73%

N=95

Age16-24 19%

25-3442%

35-44 22%

45+ 17%

Client DemographicsMonths Post Injury

<=1 year15%

1-2 yrs23%

2-3 yrs15%

3-4 yrs12%

4-5 yrs14%

5+ yrs 21%

N=95

CHI77%

CVA8%

Anoxia6%

OHI3%

Other6%

Aetiology

Living arrangements

Local B&B or Hotel accommodation Self-catering or rental Travel reimbursement for people

receiving benefits Care support Own evening meal

Stages of Assessment

Preliminary Assessment:• 1 day• 1 clinician and assistant psychologist• Neuropsychological screening assessments &

discussion with client & significant other• Future actions agreed

Detailed Assessment:• 8 days • Formal neuropsychological assessments• Functional discussion & observation • Experience aspects of the programme• Future actions agreed

Assessment Holistic neuropsychological assessment by experienced

clinical team cognitive functioning, incl. attention, memory &

executive skills perceptual skills speech & language skills, incl. social communication assessment of mood & behaviour independent living skills, incl. vocational aspects social context, incl. family & environmental

considerations

The role of ‘formulation’ The process of deriving hypotheses concerning the

nature, causes and factors influencing current problems or a client’s current situation.

Considers the multitude of possible influences on an individual’s level of functioning and psychological state

Helps clinician, clinical team and the client to understand the problems.

The role of ‘formulation’ Range of assessments and treatment

interventions carried out by different professionals.

Opportunity to bring together results of these assessments into a single coherent formulation

Promotes a shared understanding of problems - visual element useful

Aids team working

Brain pathologyStroke, head injury, etc

Cognitive Impairmente.g. MemoryPerceptionLanguageAttentionExecutive

Affecte.g. DepressionAnxietyAngerConfidenceMotivation

Physicale.g. HemiplegiaSensory lossDysarthriaPain

Functional consequencese.g. WorkADLLeisureDriving

LossInsight

Pre-morbidfactors

e.g. coping style

Family/socialsupport

Evans, Wilson et al 2009

Brain pathology

Aneurysm

Cognition & communication MemoryProblem solvingDual tasking

AffectDepressio

nWorry &

rumination

PhysicalHeadacheFatigueBody image

Personal beliefsFamily factors

A biopsychosocial model (Evans, 2002)

Loss of roleIdentity: who am I now?

Functional consequencese.g. Avoidance of childrenavoidance of anything that highlights difficulties

Holistic Neuropsychological rehabilitation aims to: enable the client to gain awareness and understanding of the consequences of his/her brain injury, facilitate acceptance and adjustment to the consequences of brain injuryenable the client to adopt compensatory strategiesTherapeutic encounters are structured around the clients’ goals that will relate to functional daily activities, participation and vocational domains.

Aims of rehabilitation

Our rehabilitation aims are to: • Improve social participation• Enable engagement in meaningful

activity in the home and community• Improve acceptance and

understanding of the consequences of brain injury

• Promote wellbeing of client and family

Sel

f-car

e

Institutio

nal

Phy

sica

l

Cultural

Social

Productivity

Leisure

Spirituality

Cognitive Physical

Affective

From Enabling Occupation: An Occupational Therapy Perspective, © CAOT 1997

Environment

Occupation

Person

Personality assessmentsInterviewsEuropean Injury QuestionnaireBrain Injury Community Rehabilitation Outcomes

Personality assessmentsInterviewsEuropean Injury QuestionnaireBrain Injury Community Rehabilitation Outcomes

Pre-morbid personality and life style

Pre-morbid personality and life style

Nature of brain injury?Severity?Extent?Location?

Nature of brain injury?Severity?Extent?Location?

Neurological investigationsImagingMonitoring over time

Neurological investigationsImagingMonitoring over time

Theories of recoveryCause of brain damage?Studies of changes over time

Theories of recoveryCause of brain damage?Studies of changes over time

How much recovery to expect?

How much recovery to expect?

Current problemsCognitiveEmotionalPsychosocialBehavioural

Current problemsCognitiveEmotionalPsychosocialBehavioural

ReassessmentReassessment

Assess to identify these in detailAssess to identify these in detail

Models of cognitive functioning

LanguageReadingMemoryExecutive FunctioningAttention

Models of cognitive functioning

LanguageReadingMemoryExecutive FunctioningAttention

Emotional and Psychosocial Models

e.g. models from Cognitive Behaviour Therapy

Effect of affect on memory, attention, etc

Emotional and Psychosocial Models

e.g. models from Cognitive Behaviour Therapy

Effect of affect on memory, attention, etc

Behavioural Models

e.g. SORKC

Behavioural Models

e.g. SORKC

Behavioural assessmentsObservations

Self report measuresinterviews

Behavioural assessmentsObservations

Self report measuresinterviews

Natural settings Simulated settings

Questionnaires ChecklistRating scales

Decide on treatment (negotiate goals with patient, family and staff members)Decide on treatment (negotiate goals with patient, family and staff members)

Will you focus onImpairmentsDisabilities orHandicap?

Will you focus onImpairmentsDisabilities orHandicap?

How will you teach/achieve this?(Refer to theories of learning)

How will you teach/achieve this?(Refer to theories of learning)

How will you evaluate success or otherwise?

How will you evaluate success or otherwise?

Will you try to Restore lost function?Encourage anatomical reorganisation?Use residual skills more efficiently?Find an alternative means to the final goal?Modify the environment?Use a combination of the above?

Will you try to Restore lost function?Encourage anatomical reorganisation?Use residual skills more efficiently?Find an alternative means to the final goal?Modify the environment?Use a combination of the above?

What evidence is there for the success of these approaches

What evidence is there for the success of these approaches

Following evaluation may need to revise approach

Following evaluation may need to revise approach

Neuropsychological assessment

PsychometricLocalisationCognitivetheoretical

modelsExclusion

modelsEcologically

validmodels

Neuropsychological assessment

PsychometricLocalisationCognitivetheoretical

modelsExclusion

modelsEcologically

validmodels

Patient and family

Patient and family

From Wilson 2009

Core Components (our reply to Prigatano core components) Therapeutic milieu Compensatory strategies Involvement of family Psychological therapy Functional & vocational meaningful

activities Shared team understanding

Stages of the Rehabilitation programme

Full Rehabilitation programme• 24 weeks total• Intensive & integration phases• 1:1 & group sessions

– Cognitive group

– Understanding Brain Injury group

– Mood Management group

– Communication group

– Psychological Support group

– Other groups

• Client-centred goal planning

Reviews 3, 6 & 12 months post-programme

IPC

Allocated at DA & for Programme/Reviews Main liaison with family and other

professionals/services Oversees programme for participants Weekly contact Co-ordinates reports & referrals

Goals Starting point at assessment with question

‘What are your goals for rehabilitation?’ Other tools used are the COPM, Rivermead

Life Goals questionnaire and individual interviews.

A team meeting is used to establish ‘SMART’ wording.

Goal Categories Understanding Brain Injury

E.g. Show an accurate understanding of her difficulties and be able to explain these to 2 relatives and 2 members of the Centre staff

Managing Daily Activities Independently E.g. To be able to prepare a simple evening

meal for the family on a weekly basis with supervision using identified strategies

Goal Categories Recreational Activities

E.g. Will be engaged in 2 chosen leisure activities on at least a weekly basis (playing pool and wood-work).

Work or Study Plans E.g. Will be engaged in a work trial and have

an identified plan for return to paid employment within 6 months.

Outcomes

Goal Achievement Standardised Questionnaires

EBIQ DEX CSI EuroQuol

COPM

Research

Research Professor Barbara Wilson OBE

Clinical team Development, application & evaluation

of developments in rehabilitation research.

Current research programme Recent presentations & publications Links with MRC

Feeling hopeless about the future

Feeling lonely

Feeling inferiorFeeling lonely, even when with othersFeeling life is not worth living

Threshold map for depression subscale of EBIQn=226 patients (baseline)

Feeling sad

Feelings of worthlessness

Preferring to be alone

Crying easily

EBIQ Depression subscale Four items with significant mis-fit therefore

removed leaving robust 5 item scale before and after data person location data

entered into t test n=44 start mean score 9.95; discharge

8.64; t = 3.4; p<0.01

Impact of rehabilitation on self rated responses to EBIQ item 9,(feeling hopeless about the future)uniform differential item function, n=44; F=4.12, p<0.05

Differential item functioning - before and after rehab.

F=4.08; p=0.04

Markers of recognition & success at OZC

Client outcomes and feedback Visiting scholars 2008-9 from Thailand, Granada

and Madrid, Toronto, Sao Paulo Published RCP guidelines for stroke Published peer-reviewed articles Published book Invited papers/conference speeches (?how many) New scholarship/learning to meet objectives eg

anatomy (ongoing) vision (workshop, collaborations ongoing)

New PhD students Lectureship in University Cambridge CLAHRC practitioner researchers

Courses

Courses

A series of courses & workshops are run each year

Can offer courses specific to needs in topics related to neuropsychological rehabilitation

Further info. on current courses go to www.ozc.nhs.uk

NeuroPage

NeuroPage Currently 40 people using service regularly Useful for people with memory difficulties,

and dysexecutive difficulties Evidence based service recent text to voice development - ideal for

those who can’t read Text messaging developments, new

“generations” of phones (eg video/image messages)

Thank you for your attention!

[email protected]