Running Head: Learning Services Program Proposal

Learning Services An Occupation-based Program Proposal

Ali Bullard
University of Utah

LEARNING SERVICES PROGRAM PROPOSAL

Introduction
The purpose of this paper is to outline a comprehensive needs assessment
and occupation-based program proposal for the community setting Learning
Services. The information in this proposal will cover the needs analysis and detailed
description of this setting, relevant literature and research done on brain injury and
social communication, a synthesis and outline of a program proposal, reasoning for
an occupational therapist to provide the services, and in-depth information on the
proposed program. The data supporting this proposal has been collected from the
settings website, observations and integration with the residents and staff,
literature and research, online sources, and interviews of managers, directors, staff
members, and residents.
Setting Description
Learning Services is an organization that provides services and living
arrangements for people who have acquired brain injuries (ABI). The services
offered nationwide are: post-acute neuro-rehabilitation, neurobehavioral
rehabilitation, supported living, and day treatment rehabilitation. It is funded
primarily through workers compensation but also can receive funding through the
military and veteran administration, private pay, auto or personal insurance, or
liability. It was originally started by two occupational therapists about 26 years ago
who saw a need for this type of service, and had a vision. Their mission statement is,
Learning Services is a national leader dedicated to building futures for persons
with Acquired Brain Injury and those who support them through person centered
community integrated rehabilitation services, and their philosophy is, Learning

LEARNING SERVICES PROGRAM PROPOSAL

Services seeks to provide a supportive and nurturing place to engage in therapeutic

and productive, develop meaningful relationships, and enjoy varied opportunities to
improve lives for persons with acquired brain injury (Learning Services, 2014).
The companys philosophical assumptions are that people with brain injuries are
valued and respected people who are capable of growth and development
(Learning Services, 2014).
There are eight Learning Services locations throughout the United States, the
setting that will be discussed in this paper is in Riverton, Utah. This Learning
Services is a supported living setting and currently has eight adult men who have
brain injuries residing. The services offered in this setting are: person-centered
services, meal planning and preparation, proactive medical care and medication
management, community integration, money management, community-based
productive activities, and recreation and leisure activities. The residents who come
the facility in Riverton typically stay long term, but there have been a few instances
when the resident transitioned to a more independent living situation. The facility
resembles a home with a kitchen, two living rooms, a sunroom, laundry room,
bedrooms, and a spacious backyard and patio. The residents all require some
assistance from staff, but their disabilities range from having tetraplegia and being
nonverbal, to only requiring assistance for high-level executive functioning skills.
The facility has 20 staff members including a program manager, case manager, life
skill trainers, program nurse, dietitian, and clinical director. There are always four
life skill trainers (LST) present during the day, three in the evening, and two
overnight.

LEARNING SERVICES PROGRAM PROPOSAL

Typically the residents see outpatient occupational, physical, and sometimes

speech therapy once a year. During these sessions the therapists evaluate and
establish goals for the residents. The LSTs are responsible for implementing the
goals throughout the year. This is done through the use of interdisciplinary
behavioral acquisition systems (IBAS). Each resident has a personalized IBAS,
which includes a daily schedule and targets (goals) for multiple areas. The IBASs are
printed out daily and the staff members document occurrences.
The IBAS targets include:

Medical (bowel movements, pressure release, confusion, VPAP, etc.)

Activities of daily living

Independent living skills (progress to this once ADLs are

independent, i.e. initiation of daily schedule, making breakfast, doing
dishes, etc.)

Behavior reduction (leaving a stressful situation, required cue to stop

non-productive talking, etc.)

Cognition (Lumosity, memory games, etc.)

Therapy extension exercises (walking, pool, gym, balance, mat, etc.)

Communication (using dynavox, etc.)

Productive activities (shopping, community outings, etc.)

The staff members document the level of supervision for each target with
prompt codes. The prompt codes are independent, positional prompt, verbal
prompt, physical guidance, gestural guidance, supervision set-up, physical prompt,
and dependent. The IBASs are inputted into a computer system and monthly reports

LEARNING SERVICES PROGRAM PROPOSAL

are generated for each resident. These reports are analyzed by the program
manager. If it is apparent that there are areas for improvement, Learning Services
will consult with health professionals for solutions. The target goals are changed as
the residents achieve them.
Community
Riverton is an urban setting with a population of 40,398, it is considered to
be apart of the Salt Lake City metropolitan area (City data, 2014). The home is
located in a residential neighborhood near many recreational and community
centers, which allows for the residents to participate in the community often.
Activities that the residents engage in frequently include: going to the gym,
ceramics, movies, out to dinner, swimming, biking, and barbeques. Other activities
that happen throughout the year include: white water rafting, snowshoeing, skiing,
hiking, hippotherapy, Lagoon, and plays.
Future Plans
The facility has plans to revamp one living room into an activities room. They
want to equip the room with many recreational and leisure stations that the
residents can participate in throughout the day. These stations may include
painting, crafts, music, building, and so on. They also have plans to redo the
backyard with more engaging elements, such as a chicken coop and adaptive
gardening. The garden would consist of archways that could be reached while
sitting in a wheelchair.

LEARNING SERVICES PROGRAM PROPOSAL

Data Collection
Staff Perspective
In order to gather data and assess the needs of this program I interviewed
the case manager, program manager, multiple LSTs, and the residents (see appendix
A for specific questions). I spent time observing and interacting with the residents
during leisure and recreational activities (including swimming at the recreation
center), cognitive activities, therapy extension activities, mealtime, and self-care
routines. I also reviewed the charts and medical histories of the residents to gain an
understanding of their diagnoses, deficits, and strengths, based on previous medical
professional evaluations. From the staff interviews I got a good understanding of
the programs offered through Learning Services. It was clear that many leisure
activities were offered to promote engagement of the residents. The LTS provide
support for ADL routines but also promoting independence as much as possible. The
staff has been trained in safe transfer and functional assist techniques. The residents
are also encouraged to engage in cognitive activities such as puzzles and games like
monopoly. When the staff was questioned about the needs of their setting, the LTSs
expressed they felt the residents needed more concrete group activities. The
program manager initially suggested I help create the new activities room, but after
discussion about the logistics we decided another project would be better, at that
point we began to brainstorm about my observation and ideas as outlined below.
Student Perspective
I initially noticed from observation of the residents that they had deficits
with social skills, consistent with typical brain injury symptoms. It was clear from

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their interaction with one another and the staff that they struggled with social skills,
such as communicating frustration, having a conversation, and being appropriate.
This observation prompted me to inquire more about the daily schedule addressing
the social needs of the residents. After inquiring with the staff, I learned that social
skills training was not an active part of their program, and all staff agreed it was a
great need. One LST informed me that they had previously tried to implement some
communication groups but they felt disorganized and did not know where to get
information or how to conduct the group. Upon review of all IBAS sheets, I found
one resident did have a social skills target, but the mechanism to achieve the goal
was obscure.
Resident Perspective
I then moved to interviewing the residents. I interviewed them about their
opinion on a social skills program, and also on their general needs and goals (see
appendix A). The residents reported that, overall, they felt their needs were being
met at the facility. Some of their goals were to be able to live independently. But
when asked about social skills specifically, all residents interviewed expressed that
they felt social skills were challenging for them, that they would like to work on
these skills, and that they were open and willing to participate in groups. I was
surprised and pleased to discover through interviewing the residents that they felt
very excited about the idea of working on their social skills. Some of them expressed
to me that their difficulty with social skills left them feeling isolated and lonely.

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Evidence-Based Practice
Acquired Brain Injury
The term acquired brain injury includes traumatic (e.g., motor vehicle
accident) and non-traumatic brain injuries (e.g., anoxic brain injury). Although an
ABI frequently leads to physical and psychological deficits, it is most often the
cognitive deficits that impact a persons ability to fully engage in daily life (Lexell,
Alkhed, & Olsson, 2013). Within the past decade, ABI inpatient rehabilitation lengths
of stay have continued to decrease (Hwan & Colantonio, 2010). Improvement in
cognitive function can continue to happen for years, and rehabilitation has been
proven to be effective even in the chronic stage of ABI (Lexell et al., 2013). This fact
illuminates the importance of establishing effective community programs to
continue rehabilitation after the acute stages.
Acquired Brain injury and Social Skills
Social skills are defined as the specific abilities required to perform
competently on a social task (Godfrey & Shum, 2000, p. 437). Impairment in social
skills and communication is nearly ubiquitous after a brain injury. This deficit is
often observed through confabulations, perseveration, inappropriate comments,
being tangential, excessive self-disclosure, interrupting, and being inpatient
(Godfrey & Shum, 2000). Other common problems include repeating oneself,
difficulty initiating conversation, and difficultly reading body language and facial
expressions (Struchen, 2014).
Because of these deficits, people with brain injuries often struggle with
sustaining friendships and forming new relationships. As a result, social anxiety

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often forms due to their inability to meet the social demands after their injury
(Godfrey & Shum, 2000; Lexell et al., 2013). About 50% of people with severe brain
injuries have limited to no social contacts one or more years after injury, and many
report loneliness and isolation (Dalhberg et al., 2006; Struchen, 2014). Other deficits
that are common after a brain injury are memory loss and emotional impairments
such as anxiety or depression. These factors also impact social interaction, for
example a person with impaired memory may not remember names or information
about people they meet (Haskins, 2012). One research study suggests that in the
chronic stage post injury, social communication is the most persistent problem, and
the loss of social contact is the most debilitating aspect of life (Thomsen, 1984).
Programming Issues and Considerations
It requires a vast amount of complex processes in order to have effective
social communication, including cognitive skills, adequate speech and language
abilities, emotional regulation, and awareness of social boundaries (Dalhberg et al.,
2006). Therefore, it is essential that program planning is multifaceted to consider
the many aspects of social communication. It is very common for this population to
have a lack of awareness of their deficit, which is known as anosognosia. This lack of
insight is one of the biggest barrier to rehabilitation of social and communication
skills (Haskins, 2012). When implementing a social skills group for this population,
it is important to consider that although lack of awareness can be successfully
addressed in groups, for some individuals with brain injury this is a barrier that will
never be overcome (Haskins, 2012).

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Effective Methods
When providing social skills training, it is crucial that the intervention
models a natural social environment so the resident is able to transfer the skills to
daily life (Godfrey & Shum, 2000). The social skills program should include mastery
experiences, role modeling, and rehearsal in situations that simulate daily life.
Mastering experiences includes the resident demonstrating their abilities,
recognizing their assets, and understanding ongoing challenges. Role modeling
includes the group leader demonstrating appropriate skills to the residents
(Kannenberg et al., 2010; Struchen, 2014). Rehearsal involves the residents
practicing learned social skills with one another (Struchen, 2014). In order to make
the skills more generalizable, skills should be incorporated into daily life rather than
solely during groups.
When treatment planning, the participants specific deficits should be
considered by the therapist in regard to what type of strategies will be used
(Haskins, 2012). If the participant has awareness of their deficits then they are more
likely to be able to use external and internal strategies. If the participant does not
have enough awareness or working memory to use these strategies, the therapist
should use a task specific approach (Haskins, 2012). Examples of external strategies
are notebooks or other visual cues. Internal strategies are used in ones conscious
control, such as self-calming breathing. Structured feedback, including both positive
aspects and areas for improvement, should be provided by the facilitator during
groups. Feedback should always be collaborative in nature, for example rather than

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saying, what you did was inappropriate the group leader should say, how do you
think that made him feel when you did that? (Haskins, 2012, p. 112).
In order to promote generalization of skills, all groups should end with a
homework assignment that is relevant to the skill learned in the group (Haskins,
2012). Another way to help the residents generalize skills is to have a community
outing that provides the opportunity for them to practice the skills with strangers
(Haskins, 2012). All groups should also focus on improving self-awareness through
strategies outlined in the Dynamic Interactional Model of Cognition, which will be
discussed in greater detail later in the proposal (Lundqvist, 2010; Toglia, 2011).
Efficacy of Group Therapy
Research shows that a structured group therapy program is one of the most
efficient ways to improve awareness of deficits (Lundqvist, 2010). Vestri et al.
(2013) determined that group therapy in conjunction with individual therapy is
more effective than individual therapy alone for people with acquired brain injuries.
In a qualitative study by Lexell et al. (2013), the participants expressed that
participating in group rehabilitation with others who had similar struggles was
helpful and healing for them, and was a huge contributor to their success.
Outcomes of Social Communication Groups
Social skills training has a rich history of successfully treating social
communication deficits (Haskins, 2012). Research shows that social skills training
promotes an increase in participation in social activities with those who have ABIs,
and higher social interaction is associated with higher life satisfaction (Godfrey &
Shum, 2000; Dalhberg et al., 2006). Furthermore, life satisfaction, community

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integration, and overall quality of life following a brain injury are highly correlated
to the level of social integration (Burleigh, Farber, & Gillard, 1997; Haskins, 2012).
Kannenberg, Amini, and Hartmann (2010) explained that social well-being is
necessary for positive mental health functioning and successful engagement in
meaningful occupations. A randomized control trial performed by Dalberg et al.
(2007) showed that adults with TBIs who participated in social skills groups scored
significantly better on the Profile of Functional Impairments in Communication than
those who received standard care. The participants involved in the social skills
groups also self-reported improvements in communication and life satisfaction six
months post-treatment. Therefore, the literature concludes that people with ABIs
who participate in social communication groups will expand their communication
skills and improve their overall quality of life.
Synthesis of Needs Assessment and Literature Review
Through evaluation of the literature and the findings throughout the needs
analysis, it is clear that social communication deficits are highly prevalent in this
population and have a great impact on quality of life. During the needs assessment I
recognized a demand for the development of social skills for the residents through
observations and interviews. I also discovered through inquiry and staff interviews
that social communication is not formally provided in their current programs. While
performing my needs analysis, I discovered the desire to improve these skills from
the residents, and enthusiasm to fill this gap from the staff. The research proved
how vital these skills are for life satisfaction for people following a brain injury
(Burleigh et al., 1997; Haskins, 2012).

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Through synthesizing the information from the needs analysis and the
research on this topic, it became apparent that a social skills program would be
most beneficial for the residents. The staff expressed interest in group activities, and
the literature strongly supports the efficacy of group models for social skill
remediation, therefore this program will be developed accordingly (Lexell et al.,
2013; Lundqvist, 2010; Vestri et al., 2013). An occupational therapist will develop
the program and run a group once a week; Learning Services staff members will run
other groups independently throughout the week. The social skills program will be
broken down into topics that will be determined through the literature review,
interviews, observations, and referral of an expert. The program will be outlined in a
binder and each topic will be confined within folders. This layout will allow the staff
to quickly access the binder and turn to a topic that they feel is relevant at that time.
During interviews with the staff members, they expressed that they wanted to run
small groups but did not know what topics to target, or how to lead a group. In
order to address this, the program will also include onsite staff training and
information within the binder that will include general tips and strategies for
running groups. The staff training will be comprised of evidence-based strategies
and group formatting techniques directly from the literature.
Theoretical Models
Theories, or practices models, are used to help guide occupational therapy
interventions with evidence and guidelines. From the many theories developed for
interventions, the two practice models that are most applicable and will guide this

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program are The Dynamic Interactional Model of Cognition (Toglia, 2011) and The
Person-Environment-Occupation Model (PEO) (Law et al., 1996).
The Dynamic Interactional Model of Cognition
This model is particularly relevant for this program because it was designed
to address cognitive dysfunction, and some assessments and treatment strategies
within the model were developed specifically for brain injury (Toglia, 2011). The
model uses a dynamic approach to cognition by analyzing the interaction between
the person, activity, and their environment. Treatment according to this model can
include enhancing the persons strategies and awareness and/or altering the
environmental factors and activity demands (Toglia, 2011). Due to the range of
resident abilities, this dynamic approach is ideal for this program. For example, the
emphasis for some residents will be to enhance their skills, while the emphasis for
others will be to alter their environment (Toglia, 2011).
Because the literature and this model both have such a heavy emphasis on
the importance of self-awareness, this program will include building the residents
self-awareness as a core feature (Lundqvist, 2010; Toglia, 2011). This will be done
through the use of pre and post self-assessments, the stop and check method,
strategy reinforcement, self-questioning methods, and strategy generation (Toglia,
2011). The program will use a hierarchy of cuing in all groups to promote the
residents to formulate responses and actions independently. The zone of proximal
development is the level of performance that can be accomplished with guidance
and cuing from someone else (Toglia, 2011). This theory implies that what someone
can accomplish with guidance indicates their potential, therefore the program will

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strive to reach the zone of proximal development for the residents. The use of
generalizable strategies will also be integrated when applicable (Toglia, 2011).
The Person-Environment-Occupation Model
This model is ideal for this program and population because it can be applied
though finding an optimal congruency between the residents and their skills, their
environmental supports and barriers at home and in the community, and their
occupations (Law et al., 1996). The overarching goal of this model is to promote
occupational performance, and more specifically with this program, the occupation
of social participation. PEO has an emphasis on the persons satisfaction with their
occupational performance, this will be a guiding force in the intervention, ensuring
the residents feel satisfied with their skills and abilities (Law et al., 1996). This
model is idyllic for a community program because it can be used to enrich and
expand the clinical approach of occupational therapy (Law et al., 1996, p. 19). It is
important to recognize that some research suggests that gains in social skills will
not be possible for everyone (Godfrey & Shum, 2000), but this does not change the
fact that it is incredibly important that those people still have the opportunity to
participate socially (Burleigh et al., 1997). For this subset of the population, the PEO
model will align the environment of the resident to promote participation, rather
than focusing on changing their skillset. This could include providing opportunities
for conversations facilitated by the therapist or group leader (Law et al., 1996).
Why an occupational therapist?
An occupational therapist would be most qualified professional to run this
program successfully. Occupational therapists are specially trained to address and

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consider multiple contexts simultaneously while viewing interventions holistically.

This is in contrast to other professionals who are trained with a more narrow
emphasis. Occupational therapists are unique from other health care professionals
because their education involves physical, cognitive, psychosocial, emotional,
environmental, and cultural aspects of disability. An occupational therapist would
be able to treat the residents and their individual needs with a thorough
understanding of the specific deficits caused by their injuries. In addition, they
would be able to evaluate the environmental supports and barriers and best adjust
them for the needs of the residents. In regards to a program for those with brain
injuries, occupational therapists have education and training on cognition, group
interventions and leadership, community program development, neuroanatomy,
gross anatomy, abnormal psychology, and psychosocial contexts. This
comprehensive educational background, along with the client-centered nature of
occupational therapy, deems this profession best for running this program.
Although staff members would be invaluable in the promotion and implementation
of groups, they do not have the background and training that is necessary to
independently achieve the goals of this program.
Goals
LTG 1: Within 9 months, residents will increase their social participation and quality
of life through enhancement of skills and/or increased opportunities for social
engagement.
STG 1: Within 6 months, 75% of residents will have at least a 15% score increase on
The Quality of Life after Brain Injury assessment.

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STG 2: Within 3 months, at least 50% of residents will attend three social skills
groups per week.
LTG 2: Within 9 months, all staff members will be competent to run social skills
groups independently while incorporating the group leadership strategies taught by
occupational therapist (see appendix B).
STG 1: Within 6 months, 100% of staff members will independently integrate a
social skill into daily life at least one time during each shift.
STG 2: Within 3 months, 100% of staff members will run at least 3 groups
independently.
The Social Communication Skills Program
This program would be developed by an occupational therapist who
would provide direct services once a week, for two hours, at Learning Services. The
program would commence with the therapist providing a training to all staff
members. The training would cover the content of the program, strategies for
running groups, general cognitive strategies to implement, and an overview of the
research that supports the program (see appendix B for staff handouts). The
following topics would be addressed in groups: listening and understanding,
reading nonverbal communication, emotional regulation, appropriate social
boundaries and rules, problem solving and conflict resolution, assertiveness,
conversation initiation, reciprocal conversations, and maintaining a topic (Haskins,
2012; Godfrey & Shum, 2000). The topics were determined through analysis of the
literature, and referral to Dr. Beth Cardell, an expert in brain injury rehabilitation. A
manual that covers these topics as well as the research and group leadership
strategies would be developed by the therapist.

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Each weekly session would begin with a debriefing with the therapist and the
staff members. This would give the staff the opportunity to ask questions and to
keep the therapist up to date with the progress of the residents. If needed, the
therapist would also provide further training and education at that time. After the
therapist and staff collaborated, the therapist would then proceed to run the social
skill group(s). The staff members would be expected to independently provide the
groups at least two other times throughout the week. Depending on the needs of the
residents, the therapist would either run one group with multiple residents, or
several smaller groups with a few residents. If possible, at least one staff member
would be encouraged to join the group to allow for role modeling and to further
train the staff members. The therapist would end each session with a homework
assignment, the staff members would help the residents in completing their
homework throughout the week. The weekly homework assignments would be
included as handouts in the manual. These homework handouts will be posted in
the common area of the house as well as in the residents rooms. Examples of
homework assignments are: initiate at least three conversations this week, and,
have a five-minute conversation without interrupting (more examples are provided
in appendix C). Each week when the therapist returned, the group would review and
discuss the homework. The staff members would be encouraged to integrate social
participation and skills into the daily life of the residents. This would be tracked
through documenting each time a skill was integrated. Between the therapist-led
group, staff-led groups, and implementation of skills and homework throughout the

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week, the staff members would spend approximately 3-4 hours a week related to
this program.
Community Involvement
The program would include community outings once a month with the
occupational therapist and staff members. These outings would be to various
restaurants, movies, coffee shops, etc. and would focus on the practice and
implementation of social communication skills in public.
Expected outcomes
The projected outcomes of this program are not only to improve and/or
promote the social interaction and communication of the residents, but also to
improve their outlook, confidence, self-efficacy, sustainability of valued occupations,
and overall quality of life (Kannenberg et al., 2010). Additionally as a result of this
program, the staff members will be confident in running social skill groups and
implementing social skills and opportunities into the daily life of the residents.
Program Evaluation
Evaluation of the residents would take place at commencement of the
program and three, six, and nine months post commencement. The therapist would
provide a dynamic evaluation of all residents before implementing program.
Evaluation would consist of administration of the Quality of Life after Brain Injury
(QOLIBRI) and the Assessment of Communication and Interaction Skills (ACIS)
(Forsyth, Lai, & Kielhofner,1999; Truelle, 2010). The QOLIBRI allows the resident to
score their quality of life in six subscales: cognition, self, daily life and autonomy,
social relationships, emotions, and physical problems (Truelle, 2010). This

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assessment would be administered individually in the sunroom, which is the most

quiet location. Because the broad aim of this program is to improve the overall
quality of life of the residents through engaging in social interaction, this scale is
appropriate in measuring those changes.
The ACIS is a formal observational assessment that measures communication
and interaction based on three domains: physicality, information exchange, and
relations (Forsyth, 1999). The ACIS is designed for the therapist to observe the
client in natural contexts that are meaningful and significant to them while they
perform their occupations (Forsyth, 1999). Further evaluation would consist of
attendance sheets from each meeting (including the group leader) and
documentation of the skills being implemented into daily life by the staff.
The therapist would also ask the residents the following questions at each
evaluation: Do you struggle with social interaction? Are you confident with your
social skills? Do you enjoy being social? And, what is your opinion of the social
communication group you attend? The therapist would ask the staff the following
questions: What is your opinion of the effectiveness of social communication
program? Have you seen changes in any of the residents since the commencement of
the program? Do you feel confident running the social skill groups independently?
And, do you have suggestions for changes in the program? Residents and staff would
be encouraged to answer open-ended in order for the therapist to gather qualitative
information.

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LEARNING SERVICES PROGRAM PROPOSAL

Space Requirements and Resident Participation
The size of the group would depend upon the topic of the day and the

residents at home at that time. All residents residing at Learning Services would be
appropriate to participate in this program, and would benefit to some degree from it
(whether they are improving their social skills or simply being presented with the
opportunity to engage with others). Groups would be held either in the sunroom,
kitchen, or living room. Groups with all eight residents and the therapist would
require at least six chairs (the other three residents could use their wheelchairs)
and could take place in the kitchen or living room. Groups with up to four residents
could comfortably fit in the sunroom.
Line Item Budget Detail
Source of Specific costs or sources of
income

Cost

Start-up Costs
1 binder $5 x 2
Paper for manual (1 ream)
Binder dividers $3 x 2
Printer ink
Sunroom table
Dining table
Chairs x 6 x $100
Whiteboard easel
Dry erase marker set

$10.00
$8.00
$6.00
$38.00
$300.00
$800.00
$600.00
$75.00
$10.00
Total= $1,846.00

Direct Costs
Assessment of Communication and
Interaction Skills: $40 x 1
Occupational therapist salary: 8 hrs per
month x 12 months x $65.00 per hour
Gasoline costs for community outings: .30 per
mile x 15 miles x 12 outings

$40.00
$6,240.00
$54.00

Total= $6,334.00
Indirect Costs
Rent 8/160 hrs per month: 10x15 space x $13 x

$1,170.00

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LEARNING SERVICES PROGRAM PROPOSAL

.05 x 12 months

Utilities 8/160 hrs per month: .05 x $100

Maintenance 8/160 hrs per month: .05 x
$1,170.00

$60.00
$58.50

Total= $1,288.50
Income

Budget
Summary
Total costs
Total income or
in-kind
contributions
Net cost of
program

In-kind contribution from Learning Services:

sunroom table, dining table, chairs,
whiteboard easel, gasoline, rent, utilities, and
maintenance

$3,117.50

Total=

$3,117.50

$9,468.50
$3,117.50

$6,351.00

Budget Narrative
At the beginning of the program the therapist will create two identical
program manuals organized in binders (one for the therapist and the other to stay
at the site with the staff). The group outlines will be printed and the topics will be
organized with dividers. Many of the groups will utilize a whiteboard easel, which is
already at the site, and the therapist will bring dry erase markers for the activities.
The Assessment of Communication and Interaction Skills can be purchased and
copied for use with multiple clients numerous times. The other evaluation tool
(QOLIBRI) is free. According to the program manager at Learning Services,
contracted occupational therapists typically get paid between $65.00-$75.00 an
hour. The residents would legally need to be transported in the Learning Services

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vans for the monthly community outings, therefore the transportation costs are
considered in-kind contributions. Due to the urban location of Learning Services, all
outings would easily take place within 7.5 miles of the home (15 miles round trip).
Considering some groups will be held in the small sunroom, and others in the larger
kitchen or living area, the estimated space requirements for the program are about
10 x 15 square feet. Because the program will take place at Learning Service and will
use the amenities already in place there, the sunroom table, dining table, chairs,
whiteboard easel, gasoline, rent, utilities, and maintenance are all considered inkind contributions.
Funding
George S. and Dolores Dore Eccles Foundation: This foundation is the top
giving foundation in Utah ($19,633,846 annually). It offers grants to a wide range of
causes, including treatment and education for those who have physical and
cognitive disabilities, health-care services in urban and rural Utah, and programs
that promote healthy lifestyles and address health challenges. The goal of the
foundation is to help make a difference in the health and well-being of all Utahns.
(George S. and Dolores Dore Eccles Foundation, 2011). This foundation fits the
social communication program very well and would be a realistic source for
funding.
R. Harold Burton Foundation: This foundation disperses $1,181,668
annually, exclusively to programs that impact residents in the Salt Lake
metropolitan area. The grants that this foundation offers are very widespread, but
cover education and health purposes. Because the social communication program

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meets these general requirements, this foundation is a feasible option for funding
(R. Harold Burton Foundation, 2014).
Summary of Agency Reaction
The program outlined in this proposal is the ideal and hypothetical version of
the similar student program that was actually implemented at Learning Services. I
was able to present the social skills manual, supporting research, and group tips to
the staff at their monthly meeting. Their response was overwhelmingly positive.
During my presentation the staff members were interested and asked many
questions. One staff member asked if they are supposed to point out deficits and
how to do so, I was able to explain the importance of building their awareness but in
a collaborative and positive way. Because this program addresses an area of need
identified by the staff, they expressed that they were very pleased and excited about
the program. Since leaving fieldwork at Learning Services, I have received emails
from the staff requesting I return to continue training and assisting with the
program. This interest and outreach suggests the staff finds the program meaningful
and foreshadows its potential success.

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Appendix A
Staff questions:
What are your funding sources?
What kinds or programming/services do you currently offer?
What are you plans for the future?
Based on what you know about OT are there any services you think an OT
practitioner could add?
What are the staff positions here?
What are their roles?
How often are the residents seen by occupational therapists and other healthcare
professional?
What is the history of the agency? How did it come about?
How do you decide when its appropriate to discharge the residents to other living
arrangements?
What does a typical day look like here?
How do the IBASs work?
After we determined a social skills program would be the most beneficial I asked:
What do you think are the most prominent social needs of the residents?
From past experience, what size group do you think would be best to hold the
sessions?
Do you think the residents would enjoy a program like this? Be willing to
participate?
Resident questions:
What are you strengths and weaknesses?
What would you like to do that you cannot right now?
What are you goals?
Are you open to participating in group actives and/or therapy?
Are social skills hard for you?
What about social skills or communicating with others is most challenging for you?
Do you think participating in groups to work on social skills would be beneficial for
you?

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Appendix B:
Staff training information, which is located in the group manual:

Group Leadership Strategies

Each group should follow this format:
1. Begin by reviewing the homework assignment from last time. Ask what
went well? What could have gone better?
2. Explain what skill we will be working on and ask them how they think
they will do.
3. Proceed with the topic as outlined.
4. After the activities let them self-reflect. This helps to build their
awareness of their abilities. Ask them questions like how do you think
that went? How did you do? What went well and what could you still
work on?
5. Explain homework assignment.
Hierarchy of cuing: This method of verbal cuing allows the residents to
generate thoughts and actions more independently. Start with cues from
level I and move to level II or III if necessary.
I. Let them do what they can, dont jump in too soon with cues, let them
think.
II. Indirect verbal cues (did you remember everything? What are you
supposed to do now? )
III. Direct cue (directly telling them the next step, e.g. Now it is your turn to
ask someone a question about themselves.)
Provide positive feedback to build confidence, but also provide feedback on
areas that need improvement. All feedback should be collaborative in nature,
rather than saying its inappropriate to say that say I wonder what else
you could have said that is more appropriate, how do you think that makes
someone feel when you say that?
Role-playing and role modeling should be included in groups. Role-playing
involves the residents practicing learned social skills with one another, and
role modeling includes the group leader demonstrating appropriate skills to
the residents.
Incorporate the skills learned in the group into daily life, this is how those
skills will transfer to real life. For example, when talking with the residents

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throughout the week encourage them to ask you questions too so it models a
more normal conversation. Reinforce the social skills when you are in the
community as well.

Why do Social Communication Groups?

Summary of Research that Supports this Program

Impairment in social skills and communication is very common after a brain

injury. Research suggests that in the chronic stage post brain injury, social
communication is the most persistent problem, and the loss of social contact
is the most debilitating aspect of life (Thomsen, 1984).
About 50% of people with severe brain injuries have limited to no social
contacts one or more years after injury, and many report loneliness and
isolation (Dalhberg et al., 2006; Struchen, 2014).
Social and communication deficits are often observed through
confabulations, perseveration, inappropriateness, being tangential, excessive
self-disclosure, interrupting, being inpatient, repeating oneself, difficulty
initiating conversation, and difficultly reading others (Godfrey & Shum, 2000;
Struchen, 2014). This program is set up to address these common deficits.
Improvement in cognitive function can continue to happen for years after
injury, and rehabilitation has been proven to be effective even in the chronic
stage of ABI (Lexell et al., 2013).
Lack of awareness of deficits is one of the biggest barriers to improving
cognitive skills. Research shows that a structured group therapy program is
one of the most efficient ways to improve awareness of deficits (Lundqvist,
2010).
Research shows that social skills training promotes an increase in
participation in social activities with those who have ABIs, and higher social
interaction is associated with higher life satisfaction (Godfrey & Shum, 2000;
Dalhberg et al., 2006).
Community integration and overall quality of life following a brain injury are
highly correlated to the level of social integration (Burleigh, Farber, & Gillard,
1997; Haskins, 2012).
Social well-being is necessary for positive mental health functioning and
successful engagement in a meaningful life (Kannenberg, Amini, & Hartmann
2010).
A randomized control trial showed that adults with TBIs who participated in
social skills groups scored significantly better on the Profile of Functional
Impairments in Communication than those who received standard care. The

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participants involved in the social skills groups also self-reported

improvements in communication and life satisfaction six months posttreatment (Dalberg et al., 2007).
Overall, research concludes that people with ABIs who participate in social
communication groups will expand their communication skills and improve
their overall quality of life.

Appendix C
Examples of homework assignments that would be assigned each week by the
therapist. These would be given as handouts to the residents, as well as posted in the
common areas.
Social Skills Homework:
When you see a stranger this week, greet them in a way that is appropriate.
Social Skills Homework:
This week, successfully resolve a conflict that happens.
Social Skills Homework:
This week, start and carryon a conversation for a few minutes. Make sure to ask
follow-up questions.
Social Skills Homework:
When you see a facial expression you dont understand, politely ask the person to
explain their emotion.
Social Skills Homework:
When you feel a strong emotion, use a calming strategy you learned.
Appendix D:
A sample of a group developed by the therapist, which could be administered by the
therapist or staff. Group outlines like this are in the manual.

Conversation Skills
Discuss good ways to start conversations
o How are you today?
o Where did you grow up?

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o What is your favorite holiday?

o What is your favorite sport?
o What is your favorite food?
o What is your favorite type of music?
Discuss the importance of asking other people questions rather than solely talking
about yourself.
o Show pie chart visual
o Whenever someone asks you a question, you should ask them one.
o Model responding to a question then asking a question.
o Role-play responding to a question then asking a question.
When the other person is talking, make sure you listen. You can show you are
listening by looking at them while they talk.
Discuss not interrupting.
o Role-play someone interrupting, talk about how that makes you
feel when someone interrupts you.
Model and role-play patiently waiting while someone you want to talk to is busy.
Discuss staying on a topic with another person during conversation and play
chain connection and un-connection game*.
Introduce the tennis court analogy- You must keep the ball bouncing back and
forth in conversation. Possibly use a real ball to pass when someone is
talking.
Discuss how to know when a conversation is done (the person stands up from the
table, starts to walk away)
Role-play how a person would act when they are leaving a conversation, and how
you would respond to finish the conversation. (It was good to see you!)
Homework: Start a conversation with someone this week and carryon a
conversation for a few minutes. We will talk about how it went next week!
*Chain connection and un-connection activity (Shaul, 2014)

This activity is designed to increase awareness of remaining on-topic in

conversation.

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Cut out the individual pieces.

While two participants are speaking together, place the chains in sequence as
long as they stay on a shared topic.
Place a broken chain piece when someone introduces a new topic too
abruptly.
Keep a broken chain prompt handy for nonverbal reminder when non
sequitur comments take place.

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