containers and write cooking directions on the containers. Matt’s supply
of containers will be sent with him at discharge. Staff is assisting Matt
in preparing two complex meals a week. Staff then assists Matt with
putting leftovers in accessible containers so that he will have several
meals to eat throughout the week.
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
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
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
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.
LIFE SKILLS / SPEECH - LANGUAGE:
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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.