HEALTHSOUTH Harmarville Rehabilitation Hospital



AT Assessment for Electronic Cognitive Device

September 29, 2010

We had the pleasure of seeing John Smith for an electronic cognitive device evaluation. John Smith is a 25 year old male with a medical history significant for traumatic brain injury resulting in cognitive impairment. John Smith currently relies on prompts from staff and peers for reminding and classroom accommodations for reading and writing difficulties; despite these supports, Mr. Smith continues to show poor punctuality, written comprehension, and writing quality. John Smith has difficulty with remembering, initiating and completing activities, speed of information processing, planning, and self-monitoring; and needs assistance in order to complete his educational program and pursue competitive employment and independent living.

Our interdisciplinary team assessment of John Smith’s cognition and communication needs determined that the Planning and Execution Assistant and Trainer (PEAT, Attention Control Systems, ) and Kurzweil 3000 (Kurzweil Education Systems, ) are the most reasonable and cost effective alternatives in meeting his needs and that John Smith also supports the recommendation. From among devices with similar functionality and cost, this equipment was chosen because John Smith preferred the operation and functionality compared to other devices tried. Use of the Kurzweil software, and synchronization of the PEAT PDA software, will require purchase of a Windows 7 personal computer and a scanner. To protect the PEAT PDA, a protective case, screen protector, and replacement styli are recommended. John Smith has demonstrated the cognitive and language skills and physical and sensory capabilities to operate this device safely and effectively. John Smith has demonstrated the motivation to use and maintain this device to increase participation in desired activities required to operate the device.

Please refer to the attached report for details as needed. The use of the ECD will significantly increase participation in managing appointments and daily tasks, medication management, written comprehension, and written communication. Mr. Smith has the ability to properly maintain the prescribed ECD independently.

Please give careful consideration in reviewing these recommendations and do not hesitate to contact us should you need clarification of his needs or have any further questions.

Sincerely,

________________________

Evaluating Clinician

AT Assessment for Electronic Cognitive Device

Date of Evaluation(s): 8/9/2010

CLIENT BACKGROUND

Name: John Smith

Date of Birth: 11/4/1984

Age: 25 years

Sex: Male

Email: jsmith@

Phone: 412-123-4567

Diagnosis: Traumatic Brain Injury

Onset: 3/25/2007

Medical Background: Experienced a closed head injury predominantly affecting the right frontal lobe. Also arthritis in neck, facial fractures, C5-6 disc protrusion.

Referral Source: Cognitive Skills Enhancement Program

Case Manager: Jane Doe

Phone/Contact: 814-987-6543

Living Situation: (describe caregiver support, family interaction) Currently living in college dormitory. At home, lives in house with parents. After graduation, plans to live independently in apartment.

Participants in evaluation: Client, rehabilitation engineer, rehabilitation counselor

Education background: High School graduate

Job Title / School Major: Pursuing Associate’s Degree in Business Management

Years: 2010-present

Job Duties / Classes: Needs to attend lectures, complete assignments (including worksheets and open-ended writing assignments), part-time job in on-campus convenience store; job duties in planned career would include filing invoices, writing reports

Leisure Interests: Painting, ceramics

Previous or Current Rehab Services: Participating in cognitive skills training program; receives occupational therapy services, counseling.

Wheelchair Information: (if applicable, describe type, model, seating system, driving controls, vendor) N/A

Existing Computer Information: (if applicable, describe access locations, operating system, CPU, speed, RAM, monitor, ports, accessories) Currently does not have a personal computer. Has access to campus computers running Windows in public computer labs.

EXISTING DEVICES:

Existing method for scheduling/memory: None / Person / Paper / PDA / Computer / SGD

Cell /smart phone / GPS / recorder /timers / alarms - Note problems/difficulties and independence

Currently relies on his own abilities and prompting from teachers, staff, and peers. Owns a standard cell phone but does not use if for scheduling.

Can current devices – phone / computer / watch / alarm be used? If not – why not?

Phone has some built-in scheduling capabilities; unknown whether these would be sufficient for his needs.

Existing method for information processing: Text-to-speech / Concept mapping

Receives classroom accommodations, such as extended time to take tests.

Can current solution be used? If not – why not?

Classroom accommodations help, but even with additional time client has written comprehension difficulties.

Current rehab AT services:

None.

Standardized Outcome Measures (PIADS, QUEST, other): N/A (no existing technology in use)

BODY SYSTEMS

Behavioral Observations (setting, compliance):

During initial meeting, client had flat affect and did not initiate communication, but responded appropriately to questions. Client does not believe he has a problem with punctuality or completing assignments, and believes that current strategies (being prompted by teachers or peers, rescheduling missed appointments) will work for him. Is willing to try some alternatives, but does not expect any change.

Client does recognize that he has difficulties with reading and is interested to try programs on the computer that might help.

Client used computers for school and recreational use prior to his injury and post-injury, and is motivated to use technology in general.

Physical (gross/fine motor):

Client has poor balance (see PT report) but has sufficient fine motor abilities to operate standard computer input devices or small controls on a portable device.

Sensory (visual acuity, tracking abilities, hearing, tactile):

Client has reduced visual acuity (see optometry report). May need magnified displays, auditory rather than visual reminders, and physical buttons that provide tactile feedback.

Cognitive: (Attention, Orientation, Speech, Language, Memory, Problem-Solving, Emotional Control):

WAIS: Verbal 87, Performance 85, Full scale 87

Behavioral Assessment of Dysexecutive Syndrome (BADS): 6-Element Task 2/4,

Zoo Map 2/4

Nelson-Denny Reading Test: Vocabulary 28%, Comprehension 14%

Test of Written Language (TOWL): Spelling 20%

In the BADS 6-Element Task, client spent most of the time on the first task (Picture Naming set A). Client quickly performed some problems from Math set A and then some items from Picture Naming set B. Client may have been avoiding dictation tasks, or may have simply run out of time.

During Zoo Map task, client appeared to ignore rule about not using certain paths twice.

ACTIVITY: Demonstrates difficulty in the following areas:

Attaining information

X Reading

( Attention/concentration

X Memory

( Verbal comprehension

X Written comprehension

( Note taking

X Speed of Information processing

( Other

Providing Information

X Writing

X Spelling

( Mathematics

X Organizing thoughts

X Organizing writing

X Verbal communication

( Other

IADL’s

( Getting up

X Prioritizing

X Appointments

( Financial / expenses

X Problem solving

( Way finding

X Medication

Management

X Sequencing Tasks

X To-Do Lists

( Behavior

Management

( Orientation to time

and place

X Initiating, sequencing, and/or

completing activities

X Planning

X Self-monitoring

( Other

Level of support or assistance needed for identified difficulty areas:

Client has difficulty with written comprehension, verbal comprehension appears to be adequate if he has sufficient time to process what is being said. When writing or speaking, client has difficulty organizing his thoughts in a timely fashion, and also has spelling difficulties. See Nelson-Denny and TOWL results above.

Client has missed 3 classes in the past week, missed two visits to the health clinic which dispenses his medication and had to be paged, and forgot two assignments. BADS results (above) indicate client has difficulty with prioritizing, problem solving, sequencing tasks, and self-monitoring.

CLIENT GOALS:

Primary Goals/ Expectations:

Client goals are to complete educational program and transition to competitive employment and independent living. To achieve these goals, client will need to consistently attend appointments and complete tasks.

Client would like to have improved reading speed and comprehension and writing quality.

Motivation to learn and use new strategies and technology:

Client is not highly motivated to pursue alternative strategies for scheduling and task management, but is willing to consider strategies and has no aversion to using technology.

Client is motivated to improve reading and writing performance, and is highly motivated to try different computer-based solutions.

Client is not motivated to improve verbal communication. Client is able to communicate functionally, but might benefit from cues to initiate conversation more often.

ENVIRONMENTS for AT use: work / school / home / community / social

Initially, client will use AT primarily in the school/dorm. Client moves from class to class and between classes, work, and dorm, but largely stays on campus. Client has substantial supervision and support from staff but no dedicated caregivers.

In long term, client’s expected work setting will be relatively stationary at a workstation, but may need to move around. Interaction with co-workers will be necessary but is not a priority to client. Client seeks independent living with minimal supervision/support.

TRIAL:

Devices Trialed, Observations and Outcomes:

Memory:

Paper Planner

Client did not consistently initiate reviewing schedule or to-do list, but did consistently carry the planner with him and was observed to initiate putting appointments and assignments into the planner.

Missed 4 class appointments, 2 pharmacy appointments, 2 assignments in 2 weeks

Cell Phone

Client had difficulty mastering the cell phone’s interface for editing the schedule. Did not initiate entering appointments.

Missed 1 class appointment, 1 pharmacy appointment, 3 assignments in 2 weeks.

PDA

Showed client the iPod Touch PDA, but client had difficulty reading text on the screen or using the touch screen with no tactile feedback. Showed client PEAT software. Client liked ability to enter voice prompts as alarm sounds, use of contrasting colors for different parts of the screen, and tactile buttons. Keyboard was more difficult to read, but client likes use of stylus rather than fingers.

Once client was comfortable with receiving reminders, taught client to independently enter reminders.

Once client was comfortable with entering reminders, taught use of untimed “to-do” tasks.

Discussed consciously prioritizing tasks using the “Priority” setting for tasks.

Client was observed to independently enter appointments and assignments and respond to cues..

During first 4 weeks with PEAT, missed 2 class appointments, 1 pharmacy appointment, 3 assignments.

During final 4 weeks with PEAT missed no appointments, 1 assignment.

Reviewing the number of appointments missed before and after use of PEAT, client recognized that the PDA did assist with managing his schedule. Client considers the level of effort required to use the PDA as worthwhile given the reduced number of missed appointments and assignments.

Reading:

Showed client Kurzweil and Read & Write Gold reading software. Client felt that Kurzweil would better maintain the formatting of scanned documents. Staff felt that Kurzweil writing tools would be more appropriate for client.

Client received training on the reading, studying, and writing tools in Kurzweil.

Scores with Kurzweil:

Nelson-Denny Reading Test: Vocabulary 52%, Comprehension 53%

Test of Written Language (TOWL): Spelling 45%

Although still indicating room for improvement, these scores indicate marked improvement from baseline. Client felt that he was able to read more comfortably and confidently with Kurzweil and liked the software.

SUMMARY/ IMPRESSIONS:

We had the pleasure of seeing John Smith for an electronic cognitive device evaluation. John Smith is a 25 year old male with a medical history significant for traumatic brain injury resulting in cognitive impairment. John Smith currently relies on prompts from staff and peers for reminding and classroom accommodations for reading and writing difficulties; despite these supports, Mr. Smith continues to show poor punctuality, written comprehension, and writing quality. John Smith has difficulty with remembering, initiating and completing activities, speed of information processing, planning, and self-monitoring; and needs assistance in order to complete his educational program and pursue competitive employment and independent living.

RECOMMENDATIONS: (Describe equipment recommendations, i.e. specifications, brand, manufacturer, or supplier source. Justification of any upgrades or features not part of the basic equipment package. Briefly explain why other lower cost alternatives were ruled out):

Our interdisciplinary team assessment of John Smith’s cognition and communication needs determined that the following equipment represent the most reasonable and cost effective alternatives in meeting his needs:

• Planning and Executive Assistant and Trainer (PEAT, Attention Control Systems, ); package includes a Windows Mobile PDA with associated charging and synchronization cables and stylus, PEAT software to run on the PDA, and PC PEAT software to synchronize the PDA schedule with a PC.

• Kurzweil 3000 (Kurzweil Education Systems, )

• Desktop Computer running Windows 7 Operating System (To run Kurzweil 3000 and the PC PEAT software)

John Smith supports the recommendation. From among devices with similar functionality and cost, this equipment was chosen because John Smith preferred the operation and functionality compared to other devices tried. John Smith has demonstrated the cognitive and language skills and physical and sensory capabilities to operate this device safely and effectively. John Smith has demonstrated the motivation to use and maintain this device to increase participation in desired activities required to operate the device. The use of this technology will significantly increase participation in managing appointments and daily tasks, medication management, written comprehension, and written communication.

Accessories:

• Scanner (to scan printed materials into the Kurzweil software)

• Protective case for PEAT PDA (e.g. NiteIze 34-2195-05 Universal Medium Horizontal Clip Case, )

• Screen protector for PEAT PDA (e.g. ProLynkz Universal Touch screen Protectors, )

• Replacement styli for PEAT PDA (e.g. HP iPaq 100 Series Replacement Stylus, )

PLAN (Include training, caregiver education, follow up treatment, follow-up outcome measures, consults to prosthetics and referrals to other sources):

Upon delivery of the PEAT PDA, further training is recommended to ensure that Mr. Smith has retained his knowledge of the PEAT functions, to ensure that Mr. Smith is successful in initially entering his schedule and appointments into the PDA, and to introduce additional features that may be beneficial for long-term use of the PDA. Upon delivery of the Kurzweil software, further training is recommended to ensure that Mr. Smith has retained his knowledge of the Kurzweil functions and to introduce additional features that may be beneficial for long-term use of the software.

For both PEAT and Kurzweil separately, the PIADS and QUEST outcome measures should be administered upon delivery of each device and at 3, 6, 9, and 12 months post delivery.

A computer access assessment is recommended to determine whether screen magnification would be beneficial for Mr. Smith in using other productivity programs on the computer.

Treatment Goals:

• No missed appointments for 1 month without client-initiated rescheduling in advance;

• No missed assignments for 1 month;

• Instructor reports of functionally improved written comprehension and written communication;

• Client satisfaction with device as measured by PIADS and QUEST.

_____________________________________ ___________________________

Evaluating Clinician Date of Report

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