DISCHARGE SUMMARY

ATTENDING DISCHARGE STAFFING:

Matthew Drake is a 24 year-old man who suffered a traumatic brain injury while serving as an active duty OIF combat soldier in Iraq on October 15, 2004. Matthew served as a driver for Special Operations in the Psychological Operations Group in the Army. His injury occurred when an improvised explosive device hit the vehicle he was driving; it is reported that he was the only survivor of this incident.

Matthew received initial emergency care at CASH (Army Hospital) followed by transportation to Landstuhl Army Medical Center in Germany on October 18, 2004 and then to the ICU at Bundeswere Zentralkrankenhaus

German Military Hospital in Koblenz on October 19, 2004. His injuries from the explosion included: depressed skull fracture, bilateral subdural hematomas, right lung contusions followed by infection, open fractures of the mandible, right facial fractures, right humeral fracture, extensive scalp lacerations, C6 fracture, extensive embedded shrapnel fragments in the right face and neck, right internal carotid artery pseudo-aneurysm, fractured sternum and clavicles, left arm laceration, and 2nd and 3rd degree burns on the right hand, thighs, and knees. A left frontopariental stroke is also noted that may have occurred on the flight to Landstuhl Army Medical Center.

Matthew has received significant support, basic medical management, and daily care needs from his mother, Lisa. Matthew has received various home health and outpatient services since November 2005, though these have not been comprehensive or focused on maximizing his medical independence. Matthew’s past medical history is significant for Tourette’s syndrome with tics.

Matt was admitted to Quality Living, Inc. on March 12, 2007 for post-acute rehabilitation. During the first 3 months of rehabilitation at QLI, the clinical focus was to decrease Matt’s learned dependency and address issues of awareness and acceptance. He moved from focusing on the things he could no longer perform to focusing on abilities he has and things he can do, and thus looking to the future with hope and optimism. Matt, with the help of the clinical team, had to overcome frustration with his situation, and learn coping strategies that no longer put him, and his care givers, in harms way (see Psychology report). Slowly, Matt gained confidence in his ability to be more independent. He learned positive daily routines developed by the clinical team, responded positively to the structure implemented for him, and learned to rely on compensatory strategies and aids to increase his independence in all settings.

Matt started a simulation in a community based apartment on October 29, 2007. Initially, QLI staff provided 24-hour support to reinforce the structure and routines that Matt had learned to rely on. Overtime, the amount of support was decreased to what he requires now; 6-8 hours on a daily basis (see Speech/Life Skills Report).

Matt’s success can be directly correlated to the consistent structure and routine that has been established for him. Any deviation to his schedule requires total staff support to problem-solve through the situation. His future attendants must fundamentally understand the importance of Matt’s routines and schedule, as well as maintain the checks and balances established at QLI to minimize safety concerns in the apartment. Matt’s apartment in Omaha was equipped with motion detectors and alarms on all of the doors. His cell phone was equipped with GPS monitoring. We highly recommend the same system be implemented in his new place of residence.

Matt’s progress and current abilities are described in detail throughout the reports below. Clinical staff will accompany Matt to his apartment in Ann Arbor and assist with the transition to his new care givers. Discharge binders have been put together for easy reference of routines and supports provided to Matt. We highly recommend his routines be followed without deviation, in order to assure Matt’s continued success.

Focus. Matt has been focusing on maximizing his independence with ADLs (activities of daily living) and home management tasks through use of compensatory strategies and the development of new routines to live in the least restrictive environment. Overall focus has been assisting Matt with increasing his independence in the simulation apartment.

Progress. Matt has made tremendous progress since his admit to QLI. Initially, Matt required 24 hour supervision and support to go through all of his ADLs and daily tasks. Through the development of consistent daily routines, Matt now requires approximately 6-8 hours of staff support. Physically, Matt is independent with most of his routines, however due to his cognitive deficits, Matt benefits from verbal cues to stay on task, follow his schedule, and for problem solving novel situations.

Current Abilities. Through structure and repetition in a familiar environment, Matt has established a routine in which he is able to complete showering, dressing, and grooming/oral hygiene independently (Organizing Items for Self-care Tasks scale). Upon waking, Matt will press speed dial #2 on his cell phone to call his father to ensure that he is up and ready to begin his day. Matt’s father will then cue Matt to take his 8 a.m. medications and get into the shower to begin his day. Matt will independently complete his shower, get dressed, and make breakfast. QLI staff call Matt at 7:30 a.m. to ensure that he has begun to cross off items that he has completed on his schedule. QLI staff arrive at Matt’s apartment at 9 a.m. to pick him up for his YMCA volunteer job.

Matt is dropped off at his apartment after working at the YMCA (approx. 11:30 a.m.) and is then able to independently and safely stay alone in his apartment and fill his free time until staff arrives at 3:30 p.m.

At times, Matt requires moderate assistance to stay on task with some evening activities. For example, he will begin to take his medications and then get on his computer and forget that he was in the process of taking his meds. Occasionally, he will begin his evening routine early and be ahead of schedule. He will cross off tasks that he has not yet completed, getting ahead of himself. Staff has been assisting Matt with staying on task and following through before beginning the next scheduled task by crossing off each task as he completes it. Once he completes his evening routine and takes his Trazadone, Matt is independent with preparing for bed and filling and putting on his CPAP. Occasionally, Matt will require staff assistance with problem solving if he over fills his CPAP machine and for maintenance of the machine.

Matt is referring to his schedule to complete laundry and simple home management tasks. Once he begins his laundry, he is independent with all tasks. Due to Matt’s ataxia, he uses Laundry Dropps®, a prepackaged laundry detergent, to allow independence with laundry. He struggles with folding his laundry "properly", but will do the best he can. He will put all clothing away independently, referring to the labels on his drawers for clothing placement. With staff supervision, Matt will refer to his schedule for a detailed list for room cleaning. Minimal cueing and assistance is required for him to complete these tasks.

A grocery shopping template has been put into place for Matt to utilize for planning and completing grocery shopping. With Matt’s assistance, staff has created a master list of grocery items that he is able to successfully prepare along with the price (to assist with budgeting) and the isle number (to assist with path finding in the grocery store). This list is on Matt’s desktop on his computer. QLI staff will assist Matt with updating his master list during the transition to Ann Arbor, Michigan. When Matt is scheduled for grocery store planning, staff assists Matt with pulling up this desktop file, printing off the list, and circling items that he will be purchasing at the grocery store. Once at the grocery store, Matt will utilize the list to find what isle the items are in and cross each item off as he places them in his cart.

Matt keeps his room neat and tidy. Staff have labeled and made written directions for where to place items to compensate for memory deficits. For example, Matt has a basket with a sign on it labeled "clean clothes for tomorrow". Matt does not require the use of bed rails. He is independent with monitoring his skin.

Matt initiates carrying his watch, wallet, schedule, phone, and keys throughout his day. Upon entering his apartment, staff no longer cue him to place these items in a shelf on the counter. He is independent with taking all of these items with him when he leaves his apartment.

Dr. Wise, neuro-optometrist, saw Matt and it was determined that he has mild suppression when reading at near out of his left eye, photophobia, myopia/astigmatism, and likely visual information processing deficits. Lasik or continuous wear contacts would be a treatment option for myopia when desired. It was also recommended that he wear polarized sunglasses for photophobia.

Recommendations. It is recommended that Matt follow his schedule and complete his routines consistently every day. There are written guidelines in the Discharge Binder for staff to follow to allow Matt the most independence. Staff support for staying on task, crossing items off his schedule, planning for new or unfamiliar events, complex cooking, and grocery shopping will be required. It is imperative that Matt’s routines stay consistent and staff provide him support to be successful with them. If not, Matt will require increased staff support to be successful throughout his day. Formal occupational therapy is not recommended.

Focus. Nursing has worked with Matt on increasing his independence with administering his own medications and managing medical self-care.

Progress. Matt demonstrated improvement in his cardiovascular health, mood, and independence administering his medications, utilizing compensatory devices, since he arrived at QLI. His alpha/beta blocker to treat hypertension was successfully discontinued by Dr. Hay in April 2007. His blood pressure remains stable.

Dr. Donaldson consulted for medication management of Matt’s depression, Tourettes, and anger outbursts. Matt responded positively to medications to treat depression, in addition to individual therapy with the psychologist for support of emotional functioning. See Psychology Report for details.

Upon admission, Matt depended upon nursing to administer his medications. Matt established routines administering his own medications utilizing a medication cassette and verbal cueing. Matt’s medication times are incorporated into his daily schedule.

Current Abilities. Matt’s skin is intact. He is independent managing his elimination. He has not experienced any seizure activity during his stay at QLI. However, an EEG completed on March 21, 2007 showed seizure potential. His cardiopulmonary health is stable. He denies pain.

Matt wears a CPAP overnight to manage sleep apnea. He is independent applying his mask once the straps are connected. He continues to require assistance to maintain the CPAP machine.

Matt is on the following medications: Trileptal 300mg twice daily for seizure prophylaxis, Aricept 10mg daily for memory, Aspirin 325mg daily for circulation, Luvox 50mg daily for Tourettes, Trazedone 75mg at bedtime for depression/insomnia, and Singular 10mg at bedtime for chronic rhinitis.

Matt administers his own medications every morning and evening utilizing a daily cassette. His medication times are incorporated into his daily schedule. He requires verbal cueing to take his morning medications. His caregivers also reorder prescriptions at the pharmacy.

Matt effectively communicates his needs to his physicians. He is able to verbalize interventions to treat minor illnesses/injuries. However, he requires assistance following his physician’s recommendations and applying his knowledge of first aid in "real life" scenarios. As well, he requires assistance scheduling physician appointments.

Recommendations. It is recommended that Matt follow up with Dr. Clay at the Ann Arbor V.A. for medical management. Additionally, he will utilize the pharmacy services on the Ann Arbor Air Force Base. He received scripts for a 30 day supply of prescription medications upon discharge from QLI. Furthermore, he is referred to the Apartment Center at Rainbow Rehabilitation with up to 10 hours of companion services.

Focus. The nutrition department has been focusing on Matt meeting his nutrition and hydration needs through his intakes to assist with weight management and overall nutritional wellness.

Progress. Matt’s most recent weight is 177 pounds. This is an 11.4 pound weight gain in the past two months. He remains within his healthy weight range of 151-185 pounds. His Body Mass Index (BMI) is 24.05, which also places him at a healthy weight.

Matt is on a regular diet with thin liquids. His appetite continues to be good. Matt batch cooks during the week with staff to have leftovers for other meals. He continues to go out to eat at scheduled times as well.

To assist with weight management, Matt has been receiving Carnation Instant Breakfast VHC three times per day. This provides an additional 1680 Calories and 67.5 grams of protein.

Current Abilities. Matt has been meeting his nutritional needs to assist with weight gain.

Recommendations. Upon discharge it is recommended that Matt continues with strategies put in place regarding meal times (scheduled eating out times, batch cooking, labeled Tupperware, etc). It is also recommended that Matt decrease his supplementation to two times per day. If Matt continues to gain weight, this may have to be decreased further. Since admission, Matt has gained 25.4 pounds, most of that being in the past four months while being in simulation. Prior to discharge, the dietitian will work with Matt’s team on getting this changed on his schedule.

Focus. The focus of Matt’s program has been decreasing gait deviations to maximize his safety and independence with all walking throughout the day. His program will include task specific activities (i.e. body weight supported gait training on the treadmill), strength and coordination activities during functional tasks, and dynamic standing balance training.

Progress. Upon admission, Matt was independent with all bed mobility, including rolling, scooting, and sit to supine to sit. Although Matt was able to bridge (raise his bottom off of the mat while lying on his back), it was not necessary for cares based on his current abilities. He was also independent with sit to stand to sit and pivot transfers. Matt ambulated community distances with and without a loft strand crutch (used crutch in right hand). Per Matt and his mother’s report, Matt preferred to walk without the crutch and tended to do so when walking in the residential setting. Matt was able to ambulate over even and uneven surfaces with close supervision. He occasionally stumbled and his base of support appeared to widen, but he was able to regain his balance independently 90% of the time. Therefore, he did not have a wheelchair as walking was his primary mode of transportation. While walking, Matt had deviations from normal gait, which increased his risk for falls (decreased knee flexion during weight acceptance, decreased heel strike, increased trunk rotation, increased base of support). His endurance was fair.

Matt’s range of motion in his arms and legs was within normal limits. Except for strength impairments in his scapular muscles, upper shoulder girdle, and hips, Matt’s strength in his arms and legs was within normal limits against manual resistance; however, strength impairments were primarily evident during performance of functional tasks, like walking or performing stepping activities. In sitting, Matt was able to withstand moderate challenges, but tended to slouch and lean backwards while sitting at the edge of the mat during all activities. With verbal cues, he was able to assume a more upright posture. When performing reaching activities, he appeared to have ataxic movements in his arms (left greater than right), but was able to reach out of his base of support above his head and down to the floor with supervision. Matt scored 11/30 on the Functional Gait Assessment. Although Matt and his mother report that he has not had a fall in nearly five months, his score on this particular balance assessment tool suggested that Matt is at high risk for falls. Stairs were not completed at the time of Matt’s assessment due to time constraints.

Matt has made progress in many areas during his stay at QLI. For example, he no longer requires a crutch to ambulate, his ambulation speed has improved, and he has become independent with walking and stairs in all settings. With regards to his walking performance and speed, Matt began at QLI on the Lite Gait with 20-40% of his body weight supported, and he ambulated at a speed of 1.0 mph. As he progressed, he demonstrated the ability to walk 3.0 mph with hands on assistance on a traditional treadmill. As a result, the gait deviations mentioned at discharge have improved, but are still present, and his base of support is decreased as well. Also, Matt’s posture throughout the day and over all strength has improved. As a result, Matt has not been receiving formal PT. Instead, we have been assisting him as necessary in completing a community based exercise program at a local exercise facility. We have assisted him in organizing his program, and he was been given workout cards to follow each time he attends the gym. He has not had any difficulties in the community and continues to demonstrate safety with walking and balance

related tasks. Matt has been consistent in completing his community exercise program with staff assistance to transition from machine to machine and to follow his exercise card.

Current Abilities. Matt is independent with all bed mobility, including rolling, scooting, and sit to supine to sit transitions. He is independent with sit to stand to sit and pivot transfers. Matt ambulates community distances independently; occasional supervision is required for path finding. While walking, Matt has deviations from normal gait, which increase his risk for falls (decreased knee flexion during weight acceptance, decreased heel strike, increased trunk rotation/decreased hip rotation, increased base of support, decreased arm swing). Matt walks independently without an assistive device over even and uneven surfaces. Matt continues to participate in activities such as walking forwards, backwards, and walking sideways on the treadmill. During these activities, Matt walks without support from his hands approximately 50% of the time, and has demonstrated fewer instances of loss of balance. For example, throughout a 20-30 minute session, he is able to walk one to two minutes without external support or hanging on with his hands. Matt has fair endurance, as he is to perform moderate strengthening exercises for 30 minutes and walk over ground for 45 minutes before increased tactile cues are needed due to safety concerns.

Matt’s range of motion in his arms and legs is within normal limits. Except for strength impairments in his scapular muscles, upper shoulder girdle, and hips (abductors and extensors), Matt’s strength is within normal limits against manual resistance. However, strength impairments are evident during performance of functional tasks, like walking or performing stepping activities. In sitting, Matt was able to withstand moderate challenges, but tended to slouch and lean backwards for stability. With verbal cues, he was able to assume a more upright posture. In standing, he tolerates light to moderate challenges but uses a wide base of support and slouched posture to increase his stability.

Recommendations. Matt is discharging from QLI to his own apartment with assistance throughout the day. It is recommended that he continue to exercise on a consistent basis throughout the week. Due to the importance of consistency in Matt’s day, it is recommended that he have regular days throughout the week to workout. In addition, it is recommended that Matt continue to follow his exercise cards with assistance from a "workout buddy" in order to be successful. For example, he benefits from cues to pick the appropriate weight, find the proper machines, and to initiate going to and from each machine. Finally, despite demonstrating safety with walking, he may also benefit from cues to scan his environment in unfamiliar situations.

Focus. The Communication and Life Skills departments have focused on transitioning Matt’s memory, organization, initiation/follow-through routines to his simulation apartment. Money management and community safety are also areas of focus. The Communication and Life Skills departments continue to collaborate with other departments on assisting Matt with decreasing negative comments about his day and life and instead focusing on positive, successful things.

Progress. Matt made significant progress during his stay at QLI. Upon admission, Matt required 24 hour supervision, was dependent on caregivers to make decisions for him, and refused to use any compensatory memory system. Currently, Matt now requires between 6-8 hours of supervision and has developed numerous routines that include compensatory memory systems to increase his independence. He is more willing to follow his routines and use his compensatory strategies because he has built in control throughout this day.

Current Abilities. Although Matt has made progress, he continues to require support to initiate and follow-through on non-routine activities and learn new information due to his poor memory. He requires assistance throughout his day and would not be safe living independently at this time.

As stated above, several routines have been developed for Matt to increase his independence. Matt continues to require maximum assistance during all new routines to be successful. Depending on the complexity of the new routine, support may be faded after several successful repetitions. Matt is independent with several routines including: morning routine, taking items when he leaves the room, completing cleaning tasks, and taking 8am and 8pm meds. In addition to his computer and PDA-type watch, several checklists and daily/hourly routines have been put into place to compensate for memory. He requires cues to appropriately use all compensatory systems.

Matt is oriented to place, person, time, and situation. He knows the month, and year, but when asked to give the day, date, he looks at his watch/schedule. Matt navigates independently to his regularly scheduled therapies and outside his apartment. When in a new environment, Matt will require maximum assistance to successfully learn the environment and walking routes.

Matt uses his daily schedule to preview and review his day. He is unable to recall what he did hours or minutes earlier, especially if it was a non-routine activity and not on his schedule, thus his detailed schedule is an essential tool to his independence. With minimal cues, he will review his schedule and has started to independently review it to see what he has scheduled next or later in the day. Very specific information is placed on his schedule. For example, at 5:00 pm on Thursday, "Buy thank you card to send to Meme for shirt from Christmas." Without this information, Matt would not know what to buy, or why he was buying an item. Please see Computer Scheduling Routine in the discharge binder for specific cues and steps to using his schedule.

Matt continues to require minimal-moderate support to cross items off his schedule. If he does not cross off the item on the schedule as he does a task, he may try to complete tasks twice, and is unable to remember if he had completed a task. He becomes minimally agitated and upset when asked to do so, however, it is crucial he be cued to cross the items off. To minimize the agitation with the cues, Matt benefits from a statement such as "You’re doing this to live independently."

Matt requires maximum support to plan, organize, initiate, and follow-through with non-routine tasks (i.e. leisure activities, free time management). Matt’s computer schedule in Microsoft Outlook is used to help him to complete these tasks. Matt is receiving minimal support to use and implement his computer scheduler and DataLink® watch. Matt can independently add and delete information if he knows what to add and delete. Without staff or his schedule, Matt will sit in his room, listen to music, and play on the computer. He will complete these tasks for 10-45 minutes at a time. After that time, he leaves his room looking for something else to do, but frequently is unhappy with his choices. He becomes the most unhappy/restless when he has unscheduled free time. Therefore, as stated above, all of Matt’s time alone is scheduled. Staff that assist Matt in the evenings have a schedule they follow as well, so they are scheduling items on the appropriate day and are consistent. Please see the Staff Schedule in the discharge binder for specific information.

Matt requires maximum assistance to generate ideas of activities and to decide what to do. Frequently, staff will cue Matt to look to his leisure activity list (see Recreation Report) for ideas of activities to do or give Matt choices of what he will do during his free time. Matt also has folders on his computer of choices for activities. Please see Recreation Report for full details regarding free time options.

Matt’s budgeting routine has several parts. All money is directly deposited. Matt has scheduled time each week to go to the bank and withdraw cash. With staff’s help, he puts $10 in an envelope for each of the following days: Tuesday and Friday and $20 in each envelope for Thursday and Saturday. Staff also give Matt an additional $30 on Saturday for groceries. Staff then give Matt his allotted envelope each morning. At the end of every day, Matt chooses whether to put extra money in an envelope to save for upcoming events or keep it in his wallet. Matt requires support for planning ahead and budgeting (i.e. withdrawing money, estimating costs). While in the community, Matt can stay within his budget and pay for services with minimal support from staff. Matt requires assistance with more complex budgeting issues (i.e. maintaining a monthly budget, paying bills). Matt saves all receipts and at the end of each day, records them in a ledger on his computer. He requires only an initial cue to get started on the routine. He then files the receipts by the month (Handling Money Scale).

Matt was given pre-teaching regarding the dangers of giving out his address, social security number, etc. A staff called Matt and presented a mock credit card application; he was adamant when stating he was not interested in the free gift or the card. A safety kit with personal supplies (band-aids, antibiotic ointment, etc.) was put together with Matt for future use. It is labeled in his apartment with instructions on what to do in case of a small cut, etc.

Matt’s writing is shaky and letters overlap. He refuses to write information due to the quality and time it takes him. Matt chooses to use his computer to make notes and schedule activities. If there is a lot of information to type in, staff will assist Matt with entering the data to minimize the time it takes, and his frustration level with the task.

Matt requires staff support to generate a list of the items needed to purchase from the store each week. He is given a master list of items that he usually buys and then he is responsible for checking his inventory. Matt goes to the same store each week which has helped him develop a familiar routine. He is able to locate the grocery section of a department store and will follow his checklist to determine the items that he needs to purchase. Matt continues to need reminders to refer to store signage to help him locate specific items but has good reasoning skills in this situation. For example, Matt knows that he is not going to find canned soup in the frozen foods section.

Matt requires minimal cueing when eating in the community. With pre-teaching and consistent expectations, Matt will talk with the hostess, find a seat, order, and pay. Matt benefits from printing the menu prior to going out to eat, deciding on a couple of items, and taking it to the restaurant. Occasionally, he will order something that he is not comfortable eating, therefore reviewing the menu before leaving, and having staff provide assistance to choose an appropriate selection is beneficial for Matt (Community Safety Scale).

Matt has used simulated public transportation, similar to A-Ride transportation in Ann Arbor, Michigan. He has a scheduled time to call with staff to set up all of his rides for the week. He also has a scheduled time to buy his tickets. Matt requires moderate assistance to schedule all of his rides. He is given 2 tickets each morning when he receives his daily money. Matt rides the bus by himself, however he must have someone meet him at his destination. He is not safe in the community by himself.

Matt demonstrates difficulty with alternating and divided attention. For example, in his apartment, Matt has attempted to cook waffles and then finish getting ready. He has forgotten his waffles and started to fix a different breakfast. Staff have required Matt to stick to his schedule and complete only one task that he can finish before starting another (Attention Scale).

Overall, Matt demonstrates slowed processing speed. This, along with his memory, affects his ability to complete lengthier and more complex tasks. When read a paragraph, Matt is able to immediately recall information when cued with questions, with 80% accuracy. However, when asked to immediately retell the story, Matt is unable to do so (Memory Scale). Matt can store some information; however, has a difficult time accessing stored information and generating it.

As stated above, Matt’s language abilities are intact. He communicates thoughts, ideas, wants, and needs. Matt is socially appropriate during conversation. Matt has difficulty with generation of language and therefore, requires cues to generate ideas on what he can do or wants to do in his free time. Given extended time and when calm, he can generate multiple solutions and solve common and many novel problems. However, due to his slowed processing, he could experience difficulties living independently when he is required to quickly come to a decision.

Matt’s speech is imprecise and slightly slurred and hypernasal. He speaks in complete sentences, but occasionally is misunderstood by unfamiliar listeners. Matt uses several speech strategies such as slowing down and taking a breath. When he concentrates, his speech is easy to understand. Matt is on a regular diet and thin liquids.

Recommendations. To maintain Matt’s level of independence, all staff that work with him should be familiar with his routines and the level of support he requires. If not, Matt will allow others to do things for him and the number of hours he will require 1-1 staff will slowly increase. We highly recommend that all staff who will be working with Matt observe QLI staff interact and give him cues/support. Staff should also utilize the Discharge Binder, which has all of Matt’s routines and cues required to continue with his current level of independence.

Continued speech-language therapy is not recommended at this time. At this time, Matt does not benefit from traditional therapy. 

Focus. Matt’s overall recreation program has focused on his quality of life by engaging him in interests that improve his emotional adjustment and enhance his independence with managing his free time. Specifically, in the Recreation Department Matt has worked on re-accessing former interests and using strategies to assist with planning trips in the community. Decreasing Matt’s amount of support during his free time through the utilization of different strategies has also been a focus.

Progress. Matt has made significant progress during his stay at QLI. Upon admission, Matt required 24 hour supervision and maximum staff assistance to help him manage his down time and comfort level with spending time alone. Additionally, Matt required full assistance with generating places to attend in the community, along with the steps involved with planning. Currently, Matt requires 6-8 hours of supervision, and with staff assistance, will plan activities to engage in during his down time when staff are not present. Matt’s comfort level with spending time alone has increased and is filled with purposeful activity. Matt’s ability to plan, with the use of compensatory strategies, has also increased during his stay at QLI.

Current Abilities. Although Matt has made progress, he still requires staff support to fill his free time with purposeful activity throughout the week. During this time, Matt refers to his "free time" list which contains a variety of activities

Matt enjoys. In the afternoon, Matt has two hours of down time in his apartment in which he is responsible for managing. Staff assist Matt in scheduling activities of enjoyment during this time. The activities range from researching and printing information about movies he would like to see from blockbuster, to looking up music by a specific artist.

As stated above, with the utilization of different strategies, Matt’s ability to manage his down time has increased. Matt utilizes a bulletin board, which is divided into different subjects (i.e. Saturday plans, Movies to rent). When Matt researches and prints off information during his free time, he pins it up on his bulletin board. Staff then assist Matt in planning this particular activity.

While at QLI, Matt attended church on a weekly basis, along with attending a bible study group on a bi- weekly basis. Matt benefits from staff assistance in packaging his offering money, $3-5 depending on what he would like. This money is what is left over from earlier in the week. Staff accompany Matt to church. Due to the increase in Matt’s comfort level and the friendships he has made, he only requires staff assistance with transportation to and from his bible study group.

One of Matt’s favorite leisure interests is bowling. Matt has shown the ability to bowl independently. While bowling, Matt benefits from reminders that "this is just a game and we are out having fun". Without these reminders, Matt, in the past, has become upset because he is not able to bowl at the same level he did pre-injury.

Matt has scheduled time during the week in which he plans places to attend in the community on specific evenings. During this planning time, although he has made progress, Matt continues to benefit from minimum to moderate staff support. Due to Matt’s inability to generate places to attend or events to do (restaurants, concerts, upcoming events in the community, etc.) specific icons have been saved to his desktop. Under each icon, weblinks are saved pertaining to the subject. For example, under the restaurant icon there are several restaurant icons saved divided into food categories (i.e. American, Italian, Mexican, etc.). This strategy along with Matt’s "restaurant book", which contains business cards of restaurants he has attended, has enhanced Matt’s ability to plan with less staff assistance. Matt is able to utilize these strategies independently, however he still benefits from minimum to moderate staff assistance for reminders to stay within budget, problem solving, and cues to complete all the steps involved (print off directions, menu and add plans to his schedule). His restaurant book and desktop file will be updated with the information for local restaurants in the Ann Arbor area.

In the realm of discovering new areas of interest, Matt has not demonstrated an ability or willingness to generate new ideas. When given options, he has thus far been resistance and often offers excuses as to why he cannot try a new activity. Matt seems to plan and participate in activities within his "comfort zone". His periods of frustration, although they have decreased, still hinder his ability to develop new meaningful relationships. Matt has stayed in contact with family and friends.

The most significant quality of life barrier for Matt appears to be his lack of acceptance of his life situation, ability to manage his anger and frustration, alcohol desires, and cognitive deficits as noted in the Speech and Psychology report. During his stay at QLI, Matt has expressed desires to order or purchase alcoholic beverages, however has been easily redirected. Matt has most certainly improved in the areas mentioned above, but they continue to be areas of risk, or barriers to his quality of life.

Recommendations. To maintain Matt’s quality of life, all staff should be knowledgeable regarding the amount of support he requires to maintain his level of independence. This type of support includes assisting Matt in scheduling purposeful activities to help him manage his free time, researching different events of enjoyment, and providing minimum/moderate support with planning. It is recommended that Matt continue to utilize the strategies put into place to assist him with being more independent. Without the use of these strategies, Matt will begin to require more staff assistance. Information regarding the amount of support needed is located in Matt’s Discharge binder. It is recommended that all staff that work with Matt utilize the Discharge binder and observe how QLI staff interact with Matt to assist him in being successful.

Focus. Matt has focused on maintaining his vocational position at the VA Hospital and his part-time job at Bakers. Other volunteer options have been investigated as well.

Progress. Matt has made progress during his stay at Quality Living, Inc. Upon admission, Matt had not held a job since his injury. He was also initially closed to all types of entry level jobs. During his stay, he first held a volunteer job at the Omaha VA (stocking for the store) where he increased his independence with basic routine tasks to the point he needed only set up on new tasks as well as occasional emotional support. He also attempted a paid position (stocking in the produce section of a grocery store), with constant supervision and support from a job coach. Most marked is the fact that Matt is now open to holding an entry level position.

Since the last update, Matt has worked at a YMCA five days per week for 3-4 hours per day. He is responsible for cleaning equipment, stocking towels, and straightening locker rooms. Staff developed lists for Matt so he could complete each task as independently as possible. He requires support for completion of all tasks.

QLI staff contacted two gyms in the Ann Arbor area. Both currently state that they do not have positions open at this time. They also stated they would be open to working with vocational rehabilitation in the future.

Current Abilities. Matt requires job coaching for starting a new job. Matt requires maximum support to learn new job tasks. Due to impairments with problem-solving and memory, he is not successful in jobs that require him to generate his own to do list or job tasks that vary day to day. In addition, Matt’s significant memory deficits do not allow him to recall what job tasks he has completed or tasks that need to be completed. He performs better at jobs that are consistent and routine and benefits from lists and structured activities; even with these strategies, Matt requires an on site supervisor and/or job coach to direct him and assist with problem solving, as well as consistent cues to complete all tasks successfully.

Matt’s first volunteer job while at QLI was at the local VA. Overtime, Matt increased his independence with completing basic routine activities to the point he needed only set up for each task and occasional emotional support. He restocked items for the canteen. He did not have a time limit for completion of his assigned tasks, and had few distractions. Matt completed the same task each day and did not interact with customers (he worked in the basement).

Matt was able to obtain paid employment at a local grocery store, Baker’s, in a produce stocking position. After several months in the position, it was evident Matt was unable to meet the requirements of the position. Even with

significant accommodations, Matt demonstrated that he required constant support for all tasks and was unable to reasonably contribute to the productivity of the company. Matt resigned from his position as a result.

Matt’s demonstrates adequate endurance to complete standing and walking tasks for 2-3 hours, though he frequently complained of being tired and having back/knee pain. Due to his ataxia, Matt is limited to the type of physical activity he is able to complete at a job (e.g. minimal lifting, no stooping, no climbing ladders). Matt requires cues to use good body mechanics when lifting. Matt is able to lift boxes that weigh an average of 15- 20 pounds.

With maximum support, Matt has developed the tools necessary for obtaining employment, which includes a resume and reference sheet. When filling out a job application, Matt also requires maximum cognitive assistance. Matt participated in mock interviews, but continues to require support to complete a real interview.

Recommendations. It is recommended that Matt continue to work with a job coach to obtain employment. He will require significant job coaching to be successful.

Focus. Matt’s primary contact in the psychology department is Jeff , Ph.D. The focus of our contacts has been ongoing assessment of and support for emotional functioning. In addition to direct services for Matt, Kristin , Counselor, is providing regular contact and counseling to Matt’s family.

Progress. Matt’s self-regulation of emotional/behavioral functioning has improved significantly since his admission. His initial "blow-ups" included a pattern of yelling, cursing, and fleeing, including dangerous behavior such as intentionally walking into traffic. The severity of his outbursts responded to behavioral interventions and redirection relatively quickly and it was only in his first few weeks at QLI that this level of anger and behavior was evidenced. Matt continues to demonstrate occasional impulsive angry reactions to frustrations that appear disproportionate to the situation, but the frequency and intensity of these instances appears to have declined, and Matt is more able to "get back on track" following such reactions.

Additionally, Matt has been able to demonstrate the ability to delay his angry reaction to situations until he is in an environment where his outburst is not so disruptive. An example of this is a situation where Matt did not have enough money to purchase a movie at Blockbuster. He did not realize this until we were in the store, but while in that public venue, he "kept his cool" and browsed titles for a bit before saying that he was ready to go home. Once in the car, and on the drive home, Matt evidenced anger and frustration by yelling and cursing, but was relatively easily redirected. Matt’s ability to "control" his anger until in a "safe" place in which to express it bodes well for continued acquisition of greater emotional self-control. When Matt does have a "blow up," the intensity is less than was previously the case, and he generally responds to verbal cues from staff relatively quickly. Staff and family members have commented on the fact that even during the times that Matt gets angry, he now requires less re-direction and less time to return back to his baseline level of emotional functioning, and the physical manifestations of anger (e.g. leaving the residence, throwing something down) are greatly reduced from their prior level.

Matt has been much less focused on the "negative" aspects of his existence over the past several months. Matt has continued his apartment simulation, and has discussed this in positive terms as a step towards demonstrating greater independence. In fact, the direct staff supervision time that Matt requires has been greatly reduced since the initiation of that apartment simulation, to the point that Matt spends more time on his own now than he does with staff

supervision or assistance. Matt has expressed a great deal of pride in the fact that he has been able to progress to this level within his recovery, where he can now begin to consider the realities of living in his own place. There continue to be times in which Matt focuses more on his losses and what he "can’t" do (e.g. drive, work the type of job that he wants, etc.) but this has been much less frequent and much easier to redirect than in our earlier sessions. There are also brief periods, usually when Matt is frustrated and irritated to be directed to "check his schedule" and confirm that something was done or not done. Matt is able to admit and understand that he needs this level of cognitive cueing in order to be successful, but is sometimes resistant to using these compensatory strategies, and requires some verbal "redirection" to get back on track.

In individual sessions with Matt, we have focused on the degree of independence that Matt is able to achieve using the schedule and routines that he has learned, and despite the fact that Matt is overtly resistant to "checking his schedule," doing so ultimately provides him with the benefit of requiring less external supervision and cueing, and therefore greater self-reliance and independence. As noted above, Matt expresses pride at the degree of independence that he has achieved, and hopes to gain even more over time. Focusing on the positive outcomes of the process, rather than his anger at having to utilize the process, appears to be a concept that Matt is able to "hold on to" and to which he responds positively.

Ongoing support regarding issues of alcohol use have appeared to have a positive effect as well, in that Matt has not spontaneously demonstrated any discussion of "wanting a beer" as was previously noted. He will still indicate that he would like to have a drink when out. This will continue to be a topic of discussion throughout our contacts, but it is encouraging that Matt has aligned his focus on more positive aspects of his recovery and increased independence in the past few weeks. There have been no reported instances of Matt attempting to obtain or talking about obtaining alcohol.

Current Abilities. Matt has been participating in all aspects of his rehabilitation program, and with regard to psychological services, has regularly attended our scheduled sessions. He remains relatively open and forthcoming in our discussions and in recent weeks has been more focused on the positive indications of his further recovery, and increased independence that he is achieving. In part, this tends to reflect his ability to "see" that things are moving in a more positive and independent direction with his moving into the apartment simulation phase of his programming. Despite the "positive" direction of his programming, and successful simulation (as evidenced by decreased direct staff supervision time), Matt continues to be resentful, at times, of the increased supervision that he receives and the perceived "loss of control" that exists.

Matt’s current emotional status has appeared to be relatively good, with a generally cheerful mood displayed, and open to discussing even some of the more challenging issues, such as alcohol use following injury, dealing with frustrations and "trigger" events in a more adaptive and positive manner, and generating positive activities in which he can engage during his "free" time. When "blow ups" have occurred, Matt has been able to resolve the issues in a relatively timely manner with external cueing and support of staff.

From the standpoint of cognitive functioning, Matt continues to evidence substantial impairment of declarative (explicit) memory functioning, and the gains that he has made in independence appears to reflect the success of establishing and maintaining positive everyday routines with cognitive supports and procedures, as well as providing cueing as necessary. Matt has responded well to the training of positive everyday routines, and has been able to adopt increasingly complex "routines" as he gains greater mastery over the simpler routines and tasks. He continues to require substantial external support for setting up these routines, for problem-solving when unexpected variation is

encountered, and occasionally needs cueing even for those routines that he is most successful at following. His substantial memory deficits continue to place him at substantial risk and vulnerability, and impede his decision-making capacity, since he cannot accurately remember important past information, or prospectively plan for his future. In functional day-to-day recall, Matt appears to be demonstrating improved "functional" memory abilities, which likely reflects his familiarization and incorporation of his compensatory routines. Despite these noted improvements, Matt continues to require substantial support within his apartment simulation for issues of cognitive deficits, particularly memory functioning. Matt’s ability to utilize a written schedule is a particular strength, and it is from this ability that he is now able to manage some relatively complex tasks with a written list of items. There are times, however, when Matt will cross off an item without fully completing it, or will fail to cross off an item after he has done it. In such instances, due to his profound memory deficits, Matt may need some external assistance for problem-solving, or cueing to complete a task that had not actually been completed.

Recommendations. In projecting support services that will be needed when Matt transitions to his next placement, it will be important that the staff in his new environment development positive and trusting relationships, and provide support and structure to Matt as needed. Ongoing monitoring of Matt’s emotional and behavioral status is recommended. Matt benefits from ongoing contact from psychology staff to assist in maintaining a positive focus to process his successes and struggles in dealing with the frustrations that he encounters.

Family Involvement. Matt has a great deal of support from his immediate and extended family as well as friends, his community, and military advocates. Matt’s parents will participate in providing him direct support each week, primarily on the weekends.

Finance. Matt’s mother, Lisa Schuster, will maintain control of Matt’s money. He is currently receiving $100/week for leisure spending with staff assistance (see Speech/Life Skills report).

Health Insurance. Matt will continue with Tricare, Medicare funding, as well as VA benefits.

Housing/Facility Options. Matt will be moving to an apartment in the Ann Arbor, Michigan community. The apartment is supervised by Rainbow Rehabilitation Center.

Support Services. Matt requires 6-8 hours of companion type support in the evenings in order to complete cooking larger meals, attending leisure activities in the community, planning for his upcoming week, and to thoroughly complete his evening routine. This support with be provided by staff from the Rainbow Rehabilitation Center. Matt requires increased support on the weekends to carry out leisure activities as well as complex daily living activities such as grocery shopping and going to the bank. This support with be provided by Matt’s parents with a tentative plan of his father picking him from his apartment on Friday night and spending that night and Saturday day at his home in Toledo, OH; then Matt would go to his mother’s house in Sylvania, OH on Saturday afternoon evening through Sunday and she would drive him back to his apartment sometime Sunday afternoon.

Matt will receive vocational support services through the Ann Arbor VA with the initial plan of participating in the VA Compensated Work Program. The initial plan is to complete this for 2-3 hours in the morning, Monday through Friday although the VA Vocational Rehabilitation Specialist will assess Matt and make appropriate recommendations.

Obstacles. As mentioned in the reports above, Matt’s severe memory deficits are his primary obstacle so the transference of his exact current routines to the new apartment is essential. Matt demonstrates a good prognosis for maintaining his current level of independence provided all strategies and routines are implemented with support as recommended.

Community Access. Matt requires staff support for accessing the community to attend leisure activities. He has participated in a simulated cab service to attend work and this will be transferred to the "A Ride" system available in Ann Arbor.

Plan. Matt’s team has completed extensive training with his parents and provided thorough information to the VA and his new caregivers from Rainbow Rehabilitation Center through verbal discussions and written reports regarding Matt’s needs. His team will also be assisting in his transition including traveling with him to Ann Arbor on March 10th, setting up all of his devices and routines in his new apartment, and monitoring him on-site for the first 10 days, and then as needed for the next several weeks. A discharge binder, complete with all of his routines and schedules, will be give to the caregivers, his parents, and the VA.