Implementation of the Comprehensive High-dose Aphasia Treatment (CHAT) program: “A different way of operating”

Figures & data

Figure 1. Project timeline for the implementation of the Comprehensive, High-dose Aphasia Treatment

Table 1. Patient Demographic Information.

	Patients
	PWA1	PWA2	PWA3	PWA4
Demographics
Gender	male	female	male	female
Age (years)	54	35	62	26
Handedness	both	right	right	right
Language	English	English	English	English
Years of Education	12	12	10	12
Occupation	Manufacturing	Corrections officer	Manager	Hospitality
Stroke
Lesion site	Left hemisphere	Left hemisphere	Left hemisphere	Left hemisphere
Lesion type	Ischaemic/Haemorrhagic	Ischaemic	Ischaemic	Ischaemic
Time Post Onset (months)	12	9	9	4

Note. PWA = Person with aphasia.

Table 2. Patients’ communication therapy goals and individualised therapy plan for CHAT.

Patient	CHAT Therapy Goals	Impairment Therapy	Functional Therapy	Computer Therapy
PWA1	To verbally express core vocabulary (e.g., family names, interests). To verbally express his radio call sign to participate in amateur radio. To increase contribution to conversations about personally relevant topics (verbally and/or using AAC).	Semantic Feature Analysis Phonological Component Analysis Verb Network Strengthening Treatment	Script training, to facilitate production of treated items and basic conversational phrases Role play amateur radio meetings and conversations Technology assessment and iPad skills revision for use in AAC	Step by step Aphasia Scripts computer
PWA2	Verbally express radio codes for emergency situation at work Write singe words and simple sentences in work scenario (e.g., logbook) To read for leisure.	Semantic Feature Analysis Phonological Component Analysis Verb Network Strengthening Treatment Repeated Increasing Speeded Retrieval	Role play emergency situations. Functional writing task (e.g., logbook entries) with compensatory strategies. Training use of adaptive and assistive technology to support reading (e.g., immersive reading).	Step by step Aphasia Scripts Repeated Increasing Speeded Retrieval
PWA3	To produce simple sentences in conversation with family on the telephone. To verbally express his food/drink orders at the café. To read a short article in the newspaper. To verbally express his personal details (e.g., name, address)	Semantic Feature Analysis Phonological Component Analysis Verb Network Strengthening Treatment	Script training, to facilitate telephone conversations, food/drink order and personal information. Role play telephone conversations and food/drink order. Training use of adaptive technology to support reading (e.g., text-to speech functionality)	Step by step Aphasia Scripts TACTUS reading and writing app
PWA4	To write a resume and job application. To retell events and important stories from her life.	Novel Approach to Real-life communication: Narrative Intervention in Aphasia (NARNIA) for narrative and procedural discourse Attentive Reading and Constrained Summarisation	Role play and narrative retell with compensatory strategies Functional vocational training (e.g., job seeking, resume and job application writing)	Constant Therapy app TACTUS Advanced Reading Comprehension app

Table 3. Outcome measures to evaluate the feasibility, acceptability and potential effectiveness of the implementation intervention and the CHAT program.

Component of Hybrid study	Outcome (Outcome Category)	Data Collection Method	Outcome Assessment period	Source	Level Data collected at
Implementation intervention (Aim 1)	Feasibility, acceptability, potential effectiveness	Semi-structured interview	Post– implementation	Clinician (self-report)	Clinician
	Potential effectiveness	Behavioural determinants survey	Baseline, Post– implementation	Clinician (self-report)	Clinician
CHAT program (Aim 2)	Feasibility	Recruitment retention log	Throughout implementation	Researcher	Patient
	Feasibility	CHAT dosage log	Throughout implementation	Clinician (self-report)	Patient
	Acceptability	Satisfaction rating	Post– implementation	Patient (self-report)	Patient
	Potential effectiveness	Clinical data (CAT, CETI, SAQOL-39) Satisfaction rating	Pre & post CHAT	Clinician	Patient
	Feasibility, acceptability, potential effectiveness	Semi-structured interview	Baseline, Post– implementation	Clinician (self-report)	Clinician

Note. CHAT = Comprehensive, High-dose Aphasia Treatment, CAT = Comprehensive Aphasia Test, CETI = Communication Effectiveness Index, SAQoL-39 = Stroke and Aphasia Quality of Life Scale-39.

Figure 2. Logic model depicting implementation intervention components, intervention functions and behavioural determinants (domains) and outcomes.

Table 4. CHAT speech pathologists’ behavioural determinants survey results (n = 2).

Domain	Pre-therapy Mean (SD)	Post-therapy Mean (SD)	Change score Mean (SD)
Behavioural regulation	2.25 (1.06)	4.75 (.35)	2.5 (1.4)
Reinforcement	2.50 (2.12)	4.67 (.47)	2.17 (1.65)
Environmental context and resources	2.40 (.0)	4.1 (.42)	1.7 (.42)
Skills	3.25 (1.06)	5.00 (.0)	1.75 (1.06)
Beliefs about capabilities	3.33 (.94)	4.5 (.24)	1.17 (1.2)
Knowledge	4.00 (.0)	5.00 (.0)	1.00 (.0)
Social role and identity	4.00 (1.41)	4.75 (.35)	0.75 (.35)
Optimism	4.25 (.35)	5.00 (.0)	0.75 (.35)
Social Influences	3.25 (1.06)	4.00 (.71)	0.75 (1.06)
Patient factors	4.00 (.0)	4.75 (.35)	0.75 (.35)
Emotion	3.25 (.35)	4.00 (.71)	0.75 (.35)
Goals	4.00 (.0)	4.50 (.0)	0.5 (.0)
Beliefs about consequences	4.33 (.94)	4.83 (.23)	0.5 (.71)
Memory, attention and decision-making	2.00 (.0)	2.00 (.0)	0 (.0)
Intentions	5.00 (.0)	4.75 (.35)	-0.25 (.35)

Table 5. Dose of comprehensive aphasia therapy received in therapy hours.

Patients	Impairment therapy	Functional therapy	Computer therapy	Group therapy	Total hours
PWA1	13.7	14	12.5	7	47.2
PWA2	14.5	12	12	7	45.5
PWA3	14	14	11	8	47
PWA4	13	11	10	6	40

Note. PWA = Person with aphasia.

Table 6. Summary of main barriers and facilitators to delivering CHAT.

Domain	Barriers to delivering CHAT	Facilitators to delivering CHAT
CHAT program structure	Flexibility and Structure (lack of program flexibility meant that clinicians did not provide a different therapy schedule if they thought it was indicated – such as less computer therapy or more functional therapy)	Clinical planning process (completing assessments early allowed spending more time deciding on therapy targets and approaches) Structured program/session guidelines (ensured delivery of full 60-minute sessions, helped clinicians design specific achievable goals) Cohort model for group therapy (facilitated safe and supportive communication environment in group therapy)
Environmental context and resources	Resource availability (e.g., StepbyStep program was only on one computer) Time limitations (for resource development and personalisation of therapy, and information gathering) Scheduling challenges (limited room availability, time required for CHAT SLPs to scheduling patient’s sessions, patient availability)	Resource availability (access to resources and therapy approaches) Staffing allocation (received assistance from allied health assistant)
Social influences	MDT attitudes and expectations in comparison to usual care (CHAT viewed as only research study and not part of the speech pathology service)	Shared workload (good working relationship between CHAT clinicians and shared experience) Clinical support (support from research team, provision of clinical supervision and expert advice) SLP team support (rooms were accessible because other GARU speech pathologists were understanding)
Memory, attention and decision-making factors	Clinician fatigue (delivering the program for the first time was tiring and clinicians felt that there should be opportunities to rotate in and out of the program)	None identified
Patient factors	Patient factors impacted dosage (conflicting specialist appointments, time lost due to medical and/or psychosocial reasons)	Patient factors (no patient fatigue, patient motivation and engagement)
Reinforcement	None identified	Patient satisfaction and positive reinforcement (appreciation from patients)
Behavioural regulation	None identified	Recording for fidelity purposes and check-ins with research team ensured consistency and accountability
Social Professional role and identity	None identified	Group identity (CHAT speech pathologists felt as though they were in a ‘bubble’ when providing the program)
Emotion	Stress (pressure and time limitations to develop personalised resources and get everything ready to start the program)	Positive emotion from experience (enjoyment and satisfaction with positive outcomes)

Note. CHAT = Comprehensive, High-dose Aphasia Treatment, SLP = speech pathologists, MDT = multidisciplinary team, GARU = Geriatric Assessment and Rehabilitation Unit.

Table 7. Patient clinical assessment results.

	PWA1		PWA2		PWA3		PWA4
Outcome Measure	Pre	Post	Pre	Post	Pre	Post	Pre	Post
CAT
Spoken comprehension	52 (52)	55 (55)	57 (57)	53 (53)	41 (46)	42 (46)	62 (62)	59 (59)
Written comprehension	45 (52)	51 (57)	46 (53)	45 (52)	37 (48)	29 (44)	56 (62)	54 (60)
Repetition	0 (34)	11 (42)*	28 (46)	26 (45)	0 (34)	10 (42)*	66 (59)	69 (61)
Naming	0 (35)	9 (45)*	51 (55)	64 (60)	0 (35)	2 (41)*	85 (71)	78 (68)
Reading	0 (38)	6 (44)*	33 (48)	45 (51)	0 (38)	0 (38)	68 (66)	68 (66)
Writing	35 (47)	49 (50)	50 (51)	52 (51)	15 (43)	11 (42)	75 (65)	75 (65)
Modality mean (t-score)	43.0	48.83*	51.67	52	40.67	42.16	64.17	63.17
CETI	41.1	78.5**	40.1	-	51.9	78.0**	89.8	93.5
SAQOL (Total)	2.41	3.05**	3.97	4.62**	4.36	4.49	4.56	4.56

Note. Pre = pre-therapy; Post = post-therapy; CAT = Comprehensive Aphasia Test; CETI = Communicative Effectiveness Index; SAQOL-39 = Stroke and Aphasia Quality of Life Scale-39. Bold = scores above cut-off; * Indicates significant change at p <.05 one-tailed according to CAT test-retest reliability data; ** Indicates score > Minimal Detectable Change 90% confidence interval (MDC₉₀).

Table A1. Potential effectiveness of implementation intervention components

Intervention component	Intervention function/s and targeted barriers	Summary of included implementation intervention elements (associated BCT strategy)	Impact of intervention elements with supporting participant quotes
Component 1: Executive and stakeholder support	Environmental restructuring Environmental Context and Resources	Obtained organisational support/commitment from executive and leadership to deliver CHAT and support from other relevant stakeholders (12.1)	Early discussions with all key stakeholders were important to obtain support: “We had meetings, we had regular phone calls, we problem solved just a little bit of that early recruitment together as well. I liaised with Dr. (de-identified) and some of the other multi-dis(ciplinary) team members earlier on.” (SLP03)
Component 2: Allocation of clinical staff	Environmental restructuring Environmental Context and Resources	Allocated clinical staff to deliver program by a) accessing new funding through university project funding (12.5) & b) using available staffing differently by allocating Allied Health Assistants to program (12.2)	a) Having two clinicians share the load and support each other facilitated implementation: “The key factor in terms of … implementing that new model is having another colleague with you to bounce ideas off … I think it would be challenging I think to do it … on your own” (SLP01) b) Receiving Allied Health Assistant support facilitated resource development: “Without the assistance of our allied health assistant we wouldn’t have gotten that (resource development and personalization) finished” (SLP01)
Component 3: Clinician training	Education Knowledge, Beliefs about capabilities	Provided background and overview of CHAT (5.1, 2.7) Educated about evidence underlying program (5.1, 2.7) Educated about outcomes for patients, services and clinicians (5.1, 5.3) Educated about specific therapy techniques (7.1) Promoted self-reflection on current practice and whether this aligns with program (2.3)	Training materials facilitated the understanding of the importance of the evidence base behind CHAT: “I love to be able to feel like I have got a better understanding of that (the evidence).” (SLP02) “Being given that time to learn about different therapy approaches that I may not have done but have heard about. Uhm like discourse therapy and NARNIA, I’ve heard about it but never really had time to read up on it and actually plan to implement it.” (SLP01)
	Training and modelling Skills, Environmental Context and Resources, Beliefs about capabilities	Provided training on key elements (including how to use specific resources including goal setting and group therapy resources) (4.1) Demonstrated key elements (6.1) Incorporated cases (8.1, 8.7) Provided feedback on specific tasks within the training session and discuss how this could impact outcomes (2.2, 2.7)	Training and modelling improved skills and confidence: “It’s all different to read it on paper but then to see it that (demonstrated) really helped. We were like ‘Aw, that’s how do it’ and you deliver that.” (SLP02) “I feel we upskilled in everything that was at its base for aphasia rehab(ilitation)” (SLP02) Learning to use a decision-making tree for therapy planning and functional tasks based on different impairments: “Running through things like clinical decision-making tree of what you would do for different types of impairment uhm and what functional tasks you could do. All of that was really important.” (SLP02)
	Persuasion Beliefs about capabilities	Training conducted by credible source with experience in delivering program (9.1) Incorporated persuasive information about consequences of CHAT into training (e.g., testimonials, patient and clinician quotes) (2.7, 5.1, 5.2, 5.3, 5.6)	Experienced training facilitator was credible: “You needed someone with experience to come up with the clinical reasoning, all that problem solving at the beginning … ” (SLP02)
	Enablement Beliefs about capabilities, Environmental Context and Resources	Provided support to set goals and develop actionable tasks (1.1, 1.3, 1.4) Provided support by promoting discussion about perceived challenges, needs, answering questions based on previous experiences (3.1)	Opportunity for questions enhanced confidence: “ … we had people that had been through running this (CHAT) previously … we had support in people to turn to and ask questions of when we weren’t sure about things.” (SLP01)
Component 4: Resource procurement and provision	Environmental restructuring Environmental Context and Resources	Provided resources to deliver program (computer programs, therapy resources) (12.5) Ensured sufficient space to provide individual, groups and computer therapy sessions (12.2) Provided access to therapy manuals (12.2) Provided access to resources to support structure of program and bookings (12.2, 12.5)	Provision of access to the resources and information about therapy approaches, Provision of templates for progress notes: “I think having access to all of those resources and the literature reviews and that bank of knowledge and information that we had access to because of the partnership with UQ and QARC … it was invaluable.” (SLP01) “The research team would kind of put together a like a draft sort of timetable to show how four people could work across those days and how it may look. We shifted that then depending on our clinical needs and what we had to attend still from a department point of view.” (SLP01)
Component 5: External & internal implementation support	Enablement Beliefs about capabilities, Environmental Context and Resources	Ongoing facilitation and support from external research team (3.2) Research-team supported clinical planning (3.2) Clinicians met after CHAT goal setting, then regularly to troubleshoot and brainstorm (1.2, 12.1) Ongoing team-based goal-setting and action planning to overcome problems (12.1, 1.5, 1.7)	Benefit of clinical planning period in ensuring best evidence-based practice; Provision of clinical supervision, expert advice, and support during the clinical planning meetings and fidelity sessions: “I really valued the clinical planning period – that time that we had with researchers uhm joining with clinicians and talking about clinical cases, and what’s best evidence-based practice for a particular impairment. Coming up with those ideas was really … It was stimulating. And that was really reassuring to be told ‘yeah, that’s the best evidence base there is.’ (SLP02) “I think the most valuable part of that whole pre assessment point of view sorry was the clinical planning day that we had with researchers and our clinical seniors because it just gave you validation that you were on the right track.” (SLP01)

Table B1.. Patient Satisfaction Survey

Survey Question	PWA1	PWA2	PWA3	PWA4
Has your communication improved since being in CHAT	5	5	5	5
Has your knowledge about your communication difficulties improved since doing CHAT?	4	5	5	5
Has your confidence improved since doing the CHAT program?	5	5	5	5
Will your new skills help in everyday life?	5	5	5	5
Were you well assessed before starting your therapy?	3	5	5	5
Were you as involved in planning and decision-making as you wanted to be?	3	5	5	5
Did you benefit from the group sessions?	5	4	5	3
Did you benefit from the individual sessions?	5	5	5	5
Did you benefit from the computer sessions?	5	5	5	5
Were the sessions relevant to you?	5	5	5	5
Was CHAT tailored to fit your wants and needs?	4	5	5	5
Were you satisfied with your progress in therapy?	5	5	5	5
Were your goals met?	5	5	5	5
Was there a good amount of family involvement in CHAT?	5	4	5	5
Did the CHAT team treat you with respect?	5	5	5	5
Were the therapists competent in providing your therapy?	5	5	5	5
Were you given enough education about aphasia during the program?	5	5	5	5
Were you given enough education about other related things (like stroke, other communication problems, etc)?	4	5	3	5
Did you receive enough written information?	4	5	5	5
Were all of your questions answered?	5	5	5	5
Was everything explained in a way you understood?	5	5	5	5
Was eight (8) weeks a good amount of time for CHAT?	4	5	-	5
Was 3-4 days per week a good weekly schedule?	4	5	5	5
Was the CHAT program planned well?	5	5	5	5
Did the program schedule run smoothly?	4	5	5	5
Was CHAT as good as you thought it would be?	4	5	5	5
Did the team respond to your feedback – your concerns, complaints, suggestions?	5	5	5	5
Did the CHAT team give you enough help to maintain/improve your skills for when you return home?	5	5	5	5
Would you recommend CHAT to others?	5	5	5	5
Overall, were you satisfied with the CHAT program?	5	5	5	5

Note. PWA = Person with Aphasia. 5-point Likert scale (1 = completely disagree; 3 = neutral; 5 = completely agree).