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... WHAT IS THE MEANING OF OCCUPATIONAL THERAPY FOR PATIENTS WITH LEFT VENTRICULAR ASSIST DEVICES IN ACUTE CARE? Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Elizabeth Wyble, OTR/L Copyright September 5th, 2017 By: Elizabeth Wyble, OTR/L All rights reserved Accepted by: Jennifer Fogo, PhD, OTR, Committee Member Cheryl Bittel, MSN, APRN-CCNS, NP-C, CCRN, Committee Member Lisa Borrero, PhD, Committee Chair Laura Santurri, PhD Director, Postprofessional Programs Stephanie Kelly, PT, PhD, Dean, College of Health Sciences University of Indianapolis ii OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Table of Contents Table of Contents.ii List of Tables..............iii Abstract...iv Chapter 1: Introduction1 Purpose.2 Chapter 2: Literature Review...........3 History..4 Exercise Post LVAD............5 Quality of Life Post LVAD..7 Interdisciplinary Approach Post LVAD..........8 Occupational Therapy Post LVAD..........9 Summary11 Chapter 3: Method.13 Study Design..........13 Participants and Recruitment.13 Data Collection..........16 Data Analysis.17 Chapter 4: Results..20 Themes...20 Chapter 5: Discussion and Conclusion..30 References..40 Appendices.46 iii OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE List of Tables and Figures Table 1 Characteristics of Participants in Study.....52 Figure 1 The Meaning of Occupational Therapy for Patients with Left Ventricular Assist Devices...53 iv OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Abstract Patients with end-stage heart failure may rely on left ventricular assist devices (LVADs) when heart transplant is delayed or not an option. Growing numbers of patients with LVADs has led to more research being performed to discover what services and support they need. None of this research has examined these patients experiences with occupational therapy in the hospital. Using the interpretative phenomenological approach (IPA) of qualitative study, semi-structured interviews of seven questions were conducted to extract the meaning of the occupational therapy services received in acute care for participants. Nine participants were recruited in a convenience sample. They were within six months of LVAD implantation, as bridge to transplant or destination therapy, and ranged from 19-78 years of age. Data analysis established four major themes: lifestyle change, caregiver support, physiological process, and occupational therapy relevance: hospital to home. The participants all viewed occupational therapy services and having an actual shower in the hospital as beneficial to their preparation for returning home. This study demonstrates that patients with LVADs perceive occupational therapy services meaningful, as they provide positive caregiving, beneficial interventions, and education during hospitalization after LVAD implantation, facilitating life change. As the number of individuals with LVADs continues to grow, occupational therapy educators, students, and practitioners need to be aware of the services they can offer patients with LVADs and the meaning these patients ascribe to occupational therapy. Increased awareness and education regarding the LVAD and support occupational therapy services offer to patients with LVADs will improve the quality of care provided. 1 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE What is the Meaning of Occupational Therapy for Patients with Left Ventricular Assist Devices in Acute Care? A heart transplant is the most desirable treatment for end stage congestive heart failure. However, a heart is not always available to a patient right away, nor is it always an appropriate solution for a patient, especially if a patient has other co-morbidities. If quality of life has decreased and/or death is imminent, a left ventricular assist device (LVAD), is often considered, making it a more common option for patients with end stage heart failure (Iseler & Hadzic, 2015). The LVAD has improved technology with a smaller sized, continuous flow pump compared to the earlier, larger pulsatile pump, allowing for increased implantation of the device into patients as bridge to transplant (BTT) or destination therapy (DT) (Lietz, 2010). With the elevated number of LVADs being placed, occupational therapy practitioners are expected to treat an increasing number of patients following their LVAD surgery. Thus, as the number of patients with LVADs increases, occupational therapy practitioners could benefit from discipline specific research involving these patients. Occupational therapy practitioners need to increase their knowledge of patients with LVADs, including analysis of appropriate interventions addressing the changing needs of these patients which could result in regaining functional independence. As the number of patients with LVADs has risen, there has been an increase in the body of research regarding this population. One area of study for patients receiving LVADs is therapeutic exercise, which is also an area of focus for occupational therapy. Prior studies have identified the importance of exercise for increasing functional independence for patients implanted with a LVAD (Bogaev et al., 2011; Hayes, Leet, Bradley, & Holland, 2012). Other areas of interest for occupational therapy practitioners identified by previous literature are selfcare and community re-entry. Prior investigators examined adjustment with transitioning back 2 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE into the home environment and the difficulties encountered on discharge, including the ability to perform activities of daily living (ADLs) (Casida, Maruccilli, Peters, & Wright, 2011). While other disciplines have performed research applicable to occupational therapy practice, they lacked occupational therapy specific information when working with patients with LVADs. The research that exists was focused from other discipline perspectives, or comprised of case studies in inpatient rehabilitation settings, and was not focused on discharge preparation (Abramson, Harvey, Greenfield, Lauman, & Metzler, 2016; Nissinoff, Tian, Therattil, Salvarrey, & Lee, 2011). In addition, there has been some qualitative research, using a phenomenological approach, addressing self-care needs and home adjustment needs of patients with LVADs, such as dressing, showering, and socializing. However, those studies have been primarily interested in the nursing or caregiver perspective. Few studies involved the patient perspective, nor did they address occupational therapy (Baker, Flattery, Salyer, Haugh, & Maltby, 2012; Casida et al., 2011; Marcucilli, Casida, Bakas, & Pagani, 2014). While those studies have contributed to qualitative knowledge regarding the patients with LVADs population, a deeper understanding of the post-operative experience from the patients perspective is needed. In addition, there are few occupational or physical therapy publications regarding patients with LVADs and those that do exist suggest that further research is needed to understand what is important to patients after LVAD surgery and how occupational therapy practitioners can help them achieve their goals (Abramson et al., 2016). The purpose of this study was to investigate the experience of hospital-based occupational therapy, from the perspective of patients who had recently been implanted with a LVAD. Current scientific literature has revealed a knowledge gap regarding patients 3 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE perceptions of how occupational therapy practitioners can assist with their transition from hospital to home after LVAD placement. By filling the gap, occupational therapy practitioners could have a better understanding of the services they might provide to assist this population. The current study sought to answer the following question using an interpretative phenomenological approach: What is the meaning of occupational therapy for patients with LVADs in acute care? Literature Review A literature search was performed, by way of multiple online databases, regarding occupational therapy services for patients with implanted LVADs. The results of the literature search demonstrated at least 14 articles supporting exercise for increased function and quality of life (QOL) for patients with LVADs (Abshire, Dennison Himmelfarb, & Russell, 2014; Ben Gal et al., 2015; Bogaev et al., 2011; Buck, 1998; Evans et al., 2011; Fernandez & Ford, 2014; Freeman & Maley, 2013; Hayes et al., 2012; Humphrey, Buck, Cahalin, & Morrone, 1998; McGarrigle & Caunt, 2016; Nicholson & Paz, 2010; Perme et al., 2006; Rogers et al., 2010; Shoemaker et al., 2014). In addition, literature was found regarding the caregiver experience post LVAD implantation (Abshire et al., 2014; Baker et al., 2010; Brouwers et al., 2011; Casida, 2005; Casida et al., 2009; Casida et al., 2011; Iseler & Hadzic, 2015; Marcuccilli et al., 2014). There was also a noted increase, as compared to five years ago, in literature involving case studies and retrospective analyses involving physical therapists and focusing on functional independence measure (FIM) scores (Alsara et al., 2014; Chu, McCormick, Hwang, Sliwa, & Rydberg, 2014; English & Speed, 2013; Hollander et al., 2014; Nguyen & Stein, 2013; Nissinoff et al., 2011; Norton, Kuhar, & Poduri, 2015; Yost, Coyle, Milkevitch, Adair, Tatooles, & Bhat, 2017). Through the course of the search there appeared to be a significant gap in the literature 4 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE regarding occupational therapy intervention for patients with LVADs, with no research in the literature demonstrating a deep understanding of the patients hospital experience following LVAD implantation. The current review was intended to further identify areas of need in the research which were beginning to develop for occupational therapy practitioners and to provide insight into what was needed from a patient perspective. History The first LVAD was implanted in the 1980s as a BTT. (Stewart & Givertz, 2012). At that time the LVAD consisted of an implanted pulsatile device into the heart that was connected via external line to a large power module on wheels. The patient was able to get out of bed to chair and may or may not have been able to walk-in the hallway. No shower was permitted, only sponge bathing, for the patients safety. The patient was not able to be discharged home and remained in the hospital until an available heart could be found. Physical limitations persisted with this large device implanted in the pre-peritoneal space, affecting pain, mobility, and food consumption. In 1998, the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure (REMATCH) study trials were initiated. This study continued until 2001 and led to the US Food and Drug Administration (FDA) approval of a modified LVAD, which was created by Thoratec to be used for DT, or as an alternative treatment to a heart transplant (Lietz, 2010). The LVAD in the REMATCH trials, though smaller and no longer pulsatile, still put great limitations on the patients functional independence. The medical and therapeutic focus for the patient with a LVAD at that time was not independence in function, but preventing deconditioning while awaiting a heart or other form of treatment (Humphrey et al., 1998). Case studies published by Buck (1998) demonstrated the importance of exercise and 5 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE mobility as part of the physical therapy treatment for patients receiving LVADs at the researchers facility. Ventricular assist device technology continued to evolve, with the development of several models of circulatory support devices, including the Thoratec HeartMate II. The HeartMate II was a smaller, continuous flow LVAD, with device implantation into the heart. It was attached to either a smaller power-based unit or battery powered by way of an external drive line and smaller controller, which could be worn on the person. Trials of this mechanical circulatory support system were completed in 2007, with FDA approval for BTT in 2008 and DT in 2010 (Lietz, 2010). Since the FDA approval of the HearthMate II, different manufacturers have designed similar devices with some variations, such as the centrifulgal force HeartWare HVAD, which was also approved by the FDA for BTT (Slaughter, et al, 2013). The smaller size of the VADs allowed for increased mobility and functional independence for patients receiving the device. However, the initial investigations of patients with LVADs postoperatively remained focused on exercise capacity and mobility, with minimal or no mention of occupational therapy services (Abshire et al., 2014; Ben Gal et al., 2015; Bogaev et al., 2011; Evans et al., 2011; Freeman & Maley, 2013; Hayes et al., 2012; Nicholson & Paz, 2010; Rogers et al., 2010; Shoemaker et al., 2014). Exercise Post LVAD Therapeutic exercise has always been identified as beneficial to patients with LVADs (Ben Gal et al., 2015; Bogaev et al., 2011; Evans et al., 2011; Hayes et al., 2012; Rogers et al., 2010). Several investigations examined exercise capacity, based on data from the HeartMate trials (Bogaev et al., 2011; Rogers et al., 2010). Exercise capacity was evaluated with 6-minute walk tests, lab values, cardiac functional status measures, and cardiac QOL measures at varying 6 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE timeframes, both pre and post implantation. Findings demonstrated that while some patients could not walk prior to LVAD implantation, they had improved activity tolerance, walked increased distances, and had improved QOL scores after LVAD implantation. The researchers results highlighted the importance of exercise and mobility after LVAD implantation for improving functional independence and QOL. However, the studies did not report from the patients perspective and did not mention exercise in relation to occupational therapy services, though this is an area within their scope of practice as it relates to the performance skills of patients (American Occupational Therapy Association [AOTA], 2014). Later studies included physical therapists and nurses along with physicians performing the research (Ben Gal et al., 2015; Evans et al., 2011; Hayes et al., 2012). With the inclusion of physical therapists and nurses, there began to be an emphasis on exercise protocols post LVAD placement and on the types of exercise performed. Exercises included cycling, treadmill ambulation, and strengthening of the upper and lower extremities. The exercises varied in the frequency of daily performance and number of repetitions. Findings of the studies demonstrated that despite the varied exercises and exercise protocols that patients experienced after LVAD surgery, increased strength, endurance, and gait distance were observed (Ben Gal et al., 2015; Hayes et al., 2012). An analysis of the current research conducted by physical therapy and nursing professionals indicated that patients with LVADs who exercised had shorter lengths of stay in the hospital (Evans et al., 2011). The above studies demonstrated the positive effect of exercise for patients with LVADs and the importance of interdisciplinary involvement during patient care. Researchers also began to recognize the importance of earlier mobility, QOL, and improved functional independence, for easier re-entry into the community after discharge. However, the investigations lacked occupational therapy and patient perspective, instead 7 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE researchers based their findings on observation, professional surveys, or retrospective chart analyses (Ben Gal et al., 2015; Evans et al., 2011; Hayes et al., 2012). Quality of Life Post LVAD In the earlier REMATCH trials, improved QOL was observed, which prompted more studies looking at overall wellbeing of patients and caregivers following LVAD implantation (Lietz, 2010). Quality of life, especially with regards to maintaining independence with self-care and home or community management were identified areas within the occupational therapy scope of practice (AOTA, 2014). As researchers became more focused on the QOL for patients with LVADs, more qualitative findings were published and concerns about the effects on caregivers came to light (Baker et al., 2010; Brouwers et al., 2011; Casida et al., 2011; Casida et al., 2009; Iseler & Hadzic, 2015; Marcuccilli et al., 2014). For example, stress of adaptation to a new way of life after the patient was implanted with a ventricular assist device was identified by caregivers (Marcuccilli et al., 2014). In particular they voiced their commitment to the patient, as well as their sacrifices. Caregiver sacrifice included leaving their jobs and incurring financial strain, as well as decreased time with friends, and decreased attention to their own health (Baker et al., 2010). In general, it appeared that LVAD implantation was a serious life change requiring time for the whole family to fully adapt (Marcuccilli et al., 2014). Casida et al. (2011), found that patients with LVADs identified the importance of hospital staff assisting patients and caregivers with the transition from life before LVAD implantation, to returning home after implantation. Transitional assistance was not just for physical changes, but also for social and emotional needs of the patient and family. Though nursing focused, the study touched on areas within occupational therapy scope of practice, including home modification, which consisted of rearranging furniture to fit the power-based 8 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE unit, and to make moving with the power cord safe. In addition, self-care was addressed, especially fear of the first shower at home, post LVAD placement. The AOTA (2014) described one of the goals of occupational therapy as aiding patients and families with the transition and adaptation to life changes after a significant health event. Perhaps occupational therapy practitioners could provide this service for patients with LVADs and their families or caregivers. An in-depth understanding of the needs of these patients during hospitalization, aftercare, and on discharge would provide a guide for occupational therapy practitioners to help patients and caregivers with these transitions. Interdisciplinary Approach Post LVAD In recent years, a multidisciplinary, evidence-based approach to the treatment of patients receiving LVADs has been emphasized. (Alsara et al., 2014; Chu et al., 2014; English & Speed, 2013; Fernandez & Ford, 2014; Hollander et al., 2014; McGarrigle & Caunt, 2016; Murray et al., 2009; Nguyen & Stein, 2013; Nicholson & Paz, 2010; Norton, Kuhar, & Poduri, 2015; Shoemaker et al., 2014; Yost et al., 2017). The majority of these studies occurred in an inpatient acute rehabilitation setting and were published as case studies or retrospective analyses of patient charts. Some studies were physical therapy focused, looking at the benefits of exercise and mobility for patients with LVADs and other assistive heart devices (Fernandez & Ford, 2014; McGarrigle & Caunt, 2016; Nicholson, & Paz, 2010), while other studies looked at FIM score comparisons (Alsara et al., 2014; Chu et al., 2014; English, & Speed, 2013; Nguyen, & Stein, 2013; Norton, Kuhar, & Poduri, 2015; Yost et al., 2017). The FIM is the most commonly used assessment in the inpatient rehabilitation setting, and measures daily living skills and mobility independence on a seven point scale with one being total assistance and seven being independent (Alsara et al., 2014). The patients reviewed in the studies received standard care appropriate to 9 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE an inpatient rehabilitation unit, with daily occupational, physical, and speech therapies, in addition to nursing and physician care. The results of the investigations demonstrated significant functional gains during inpatient rehabilitation stays, according to higher FIM scores at discharge as compared to admission scores (Alsara et al., 2014; Chu et al., 2014; English & Speed, 2013; Nguyen & Stein, 2013; Norton, Kuhar, & Poduri, 2015; Yost et al., 2017). The studies involved single-group cohorts who received inpatient acute rehabilitation services. There was no comparison to groups not receiving the acute rehabilitation services, therefore limiting the reliability of the studies assumptions that this setting was more effective for improving patient function than another setting. Comparison of differing treatment and non-treatment groups would be important for future evidence-based practice. The investigations highlighted the importance of the interdisciplinary team, explaining that the patients benefited from the services provided. However, they did not give any detail regarding the scope of occupational therapy services involved. These studies did not give any insight into the patients perceptions of their rehabilitation and no information was provided regarding the care that occurred in the acute care setting prior to inpatient rehabilitation admission. Occupational Therapy Post LVAD In 2004, Shepherd and Wilding published not a research study, but a discussion regarding what occupational therapy could possibly offer patients implanted with LVADs. The authors discussed the role of occupational therapy, involving exercise through purposeful activity, LVAD equipment safety, self-care, and education of patients and caregivers. They identified patients with ventricular assist devices as a growing population, needing occupational therapy support for functional living. While these topics are still applicable, this article was published prior to the HeartMate II trials and the technology referenced in the article would not be relevant 10 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE to current healthcare practice. Other narratives, such as that of Abramson et al. (2012) and McIntyre (2007) provided general overviews of mechanical circulatory system technology and occupational therapy considerations and interventions. The authors provided general information regarding occupational therapy services across healthcare settings and reported that the occupational therapy intervention appeared beneficial to patients. However, the McIntyre (2007) article had inaccuracies with regard to self-care interventions, possibly due to out of date information. Both articles ended by requesting that evidence-based research be conducted to support occupational therapy services, for patients receiving mechanical circulatory support. More recently, Padmanabhan and Thankachan (2011) published a discussion of the phases of occupational therapy treatment provided throughout the healthcare continuum for patients with LVADs. The authors described their own protocols used in acute care, inpatient rehabilitation, home health, and outpatient services. Their protocol was a six-phase intervention, including routine occupational therapy activities such as the initial evaluation, positioning, range of motion, splinting, ADLs, energy conservation, upper extremity coordination, and endurance building. The focus on ADLs began at bedside with feeding and grooming, and then moved to advanced self-care tasks, such as shower kit training, including the equipment and precautions needed for the LVAD. Upper extremity coordination was important for general LVAD management, involving manipulation of the power connectors and moving from the power-based unit to battery power. Occupational therapy also assisted with the discharge planning for the patient and family. The patients remained in the hospital or inpatient rehabilitation setting until they were independent with their LVAD and daily living skills, or they moved on to another level of care. The final phases of care involved moving the patient to long-term acute care, a skilled nursing facility, outpatient setting, or home health. Throughout all phases, education was 11 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE provided to patients and caregivers (Padmanabhan & Thankachan, 2011). The authors reported successes, with patients achieving improved function and caregiver satisfaction with the described methods of occupational therapy intervention. However, the reported successes are the authors opinions of the results of interventions they believed are best practice. Their protocols had not been studied for their effectiveness by a quality research design, nor had they been compared to other possible interventions. The authors discussed gaps in evidence-based literature demonstrating the benefits of occupational therapy for individuals with a ventricular assist device, as well as the need to further explore how occupational therapy practitioners could assist patients and their families transition from hospital to home. Summary Overall, there appeared to be agreement among researchers that the number of patients with LVADs was growing and that healthcare professionals, including occupational therapy practitioners, needed to know more about these patients and their care (Abramson et al., 2012; Alsara et al., 2014; Chu et al., 2014; English & Speed, 2013; Evans et al., 2011; Hollander et al., 2014; McIntyre, 2007; Murray et al., 2009; Nicholson & Paz, 2010; Nguyen & Stein, 2013; Norton, Kuhar, & Poduri, 2015; Padmanabhan & Thankachan, 2011; Shepherd & Wilding, 2004; Shoemaker et al., 2014, Yost et al., 2017). Interventions such as exercise and improving performance in ADLs have been analyzed for the LVAD population, but lacked occupational therapy specific guidelines (Ben Gal et al., 2015; Bogaev et al., 2011; Casida et al., 2011; Evans et al., 2011; Hayes et al., 2012; Rogers e. al., 2010). In addition, many case study presentations and retrospective studies focused on FIM scores achieved in inpatient rehabilitation settings (Alsara et al., 2014; Chu et al., 2014; English & Speed, 2013; Nguyen & Stein, 2013; Nissinoff et al., 2011; Norton, Kuhar, & Poduri, 2015; Yost et al., 2017), while other case studies were 12 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE concerned with physical therapy and early mobility (Fernandez & Ford, 2014; Nicholson & Paz, 2010; Perme et al., 2006). These studies provided no support for occupational therapy services, nor did they describe the patients in-depth experience during the interventions. Current literature demonstrates a lack of patient-reported outcomes for patients with LVADs (Brouwers et al., 2011). Many studies related to the post-operative patient with a LVAD are quantitative in nature (Alsara et al., 2014; Bogaev et al., 2011; Chu et al., 2014; Hayes et al., 2012; Murray et al., 2008; Nguyen & Stein, 2013; Norton, Kuhar, & Poduri, 2015; Rogers et al., 2010; Shoemaker et al., 2014; Yost et al., 2017). Quantitative studies lack the deeper inquiry and understanding that can be derived from a qualitative research study. The few published qualitative studies are typically related to QOL, they are from the caregiver or family perspective, and the authors failed to provide insight that could have been offered from the patient, particularly directly after LVAD implantation, while the patient remained in the hospital (Baker et al., 2010; Brouwers et al., 2011; Casida et al., 2011; Casida et al., 2009; Iseler & Hadzic, 2015; Marcuccilli et al., 2014). There is clearly a need for additional patient-reported research from the individuals receiving LVADs. A gap in the literature exists for demonstrating the services and benefits occupational therapy could offer for LVAD intervention in the acute care setting. Further qualitative research delving into the in-depth patient perspective of occupational therapy services should to be pursued in order to better understand and serve the growing numbers of patients being implanted with LVADs. A qualitative investigation would provide occupational therapy practitioners with the insight needed to meaningfully assist patients who were adapting to the significant life change that occurs post LVAD implantation. To this end, the investigator of the current study 13 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE utilized interpretative phenomenology to answer the research question, What is the meaning of occupational therapy for patients with LVADs in acute care? Method Study Design Interpretative phenomenological approach (IPA) was the qualitative approach used in this study. With its psychological focus, Smith, Flowers, & Larkin (2009) described IPA as analyzing the experience of a major occurrence in someones life and his or her view of its significance. Specifically, IPA addresses a time of major change in ones life; for example, the researcher may want to understand the process relating to the placement of a LVAD and the changes that occurred postoperatively in a patients life. Interpretative phenomenology is said to be double hermeneutic because the researcher was attempting to find meaning in the participants meaning of their experience (Smith et al., 2009). Interpretative phenomenology based on Van Manens hermeneutic phenomenological approach (Van Manen, 1990) has been used to describe the experience of spousal caregivers for patients receiving LVADs (Casida, 2005) and the experience of LVAD patients during sex and intimacy (Casida, Marcuccilli, Peters, & Wright, 2011). It was anticipated that the deeper meaning derived from IPA would provide greater insight for occupational therapy practitioners regarding the significant life change endured by patients with LVADs, after being implanted with the device. This would help occupational therapy practitioners understand what was important to these patients, and provide insight into how they could better serve patients who had been implanted with a LVAD. The current study explored the meaning of occupational therapy for patients with a LVAD in the acute care setting. Sample Selection and Recruitment 14 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Participants In keeping with a qualitative approach (specifically IPA) a convenience sample of nine participants were selected, with the goal of finding common themes in the data. The study incorporated the following inclusion criteria, which was in keeping with prior studies by Casida (2005) and Casida et al. (2011): Male or female Able to follow 3-step commands 18 years of age or older Received a left ventricular assist device as either BTT or DT within the last 6 months Received occupational therapy, including shower kit training in the acute care setting, prior to discharge home. As the tenets of IPA emphasize a concentrated focus on receiving detailed accounts of the patient experience, with quality, not quantity being the primary goal, a sample of nine participants is appropriate for this study (Smith et al., 2009). Interviews were conducted with nine participants, including four women and five men. Participants had an age range of 19 78 years, with a mean age of 52 years. Six participants were African American and three participants were Caucasian. Seven participants had received HeartWare LVADs, while two had been implanted with HeartMate II devices. Four patients received LVADs as BTT, while five were designated as DT. The mean number of days post LVAD implantation was 85. While not all participants were married, they all had family support. Characteristic information is summarized in Table 1 (see Appendix E). Recruitment 15 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Institutional Review Board approval was obtained prior to recruitment, and data collection from both Emory Saint Josephs Hospital (ESJH) and the University of Indianapolis. Recruitment and data collection took place in the outpatient Congestive Heart Failure Clinic at ESJH during or after a follow up visit for patients who were post LVAD placement. Recruitment proceeded as follows: The primary investigator developed a flyer which included a short description of the study, general inclusion criteria, the nature of the procedures, estimated time commitment, location, and a short description of the investigator and her contact information (see Appendix A). The primary investigator provided copies of the flyer to the LVAD nurse/coordinator performing follow-up visits with patients. During the course of regularly scheduled heart failure clinic appointments, the LVAD nurse/coordinator gave the flyer to patients who potentially met the inclusion criteria. She provided limited information to the participant by way of a written script (see Appendix B). Patients who met the inclusion criteria were identified by the LVAD nurse/coordinator. The LVAD nurse/coordinator received permission from these patients for their contact information to be provided to the primary investigator, and told them that they would be contacted by the primary investigator (see Appendix B). The LVAD nurse/coordinator provided this information to the primary investigator using a password protected email account within the ESJH secure network. The LVAD nurse/coordinator made it clear to the patients that participation in the research study was voluntary. The primary investigator contacted these patients by telephone, to confirm their eligibility for the study and to answer any questions. When a patient expressed interest in participating in the research study, the primary investigator and patient set up a time to meet at the clinic to 16 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE complete the informed consent process and conduct the interview. The primary investigator then mailed a hardcopy of the informed consent document to the patient for review prior to the faceto-face informed consent process and interview. Data Collection Data collection consisted of one face-to-face semi-structured interview with each participant. Informed consent (see Appendix C) was obtained when the patients and primary investigator came together for the interview meeting. During the informed consent process, the primary investigator read through the informed consent document with the patients and responded to any questions or concerns. The primary investigator verbally reviewed the study title, purpose, information regarding how the patients information would be used, and included an explanation of how the patients confidentiality would be maintained. If the patients agreed to participate in the study, they signed the consent, along with primary investigator. For each participant, the semi-structured interviews took place in one of the heart failure clinics private consultation rooms at a time convenient to the patients. The interviews, which lasted and average of 30 minutes each, were face-to-face, audio-recorded, and consisted of a predetermined set of questions (See Appendix D). During the interviews, the primary investigator asked the participants for further clarification as needed, and asked probing questions to facilitate better understanding of the participants experiences. These procedures were consistent with those recommended by Smith et al. (2009) for an interpretative phenomenological analysis, and were similar to those utilized by researchers examining similar phenomenon (Casida, 2005; Casida et al., 2011). Participants began the interviews by reflecting on their experience in the acute care hospital setting. They all discussed their experiences just after surgery, with some reporting 17 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE difficulty remembering everything due to medications received or temporary altered mental status. In general the participants focused on interactions with hospital staff, the processes surrounding getting accustomed to their new LVADs, and the education and preparation they received prior to going home. Interviews were concluded with the participants descriptions of the transition and experience upon returning home. Prior to, and in between interviews, the primary investigator used bracketing procedures consisting of journaling, to express her own thoughts, opinions, reactions, and feelings in reaction to the interview process and content. Bracketing is considered hermeneutic or interpretive, as it helps to decrease the possibility of biases and assumptions regarding the experiences being studied, although a basic tenant of qualitative research is that some level of bias is to be expected when in-depth, personal information is sought from participants (Fischer, 2009). Bracketing, including journaling, allows researchers to acknowledge their opinions on a subject and then reflexively examine and interpret them as part of an ongoing process during data collection and analysis. By bracketing and reflecting on his or her assumptions, a researcher becomes more self-aware and is able to see different meanings in assumptions or perceptions, which may change ones viewpoint (Fischer, 2009). In this study, bracketing and disclosure of the investigators and colleagues backgrounds were used throughout data collection, analysis, and documentation of the findings. Data Analysis A coding system was used to identify participants on all transcripts and demographic characteristic logs in order to maintain confidentiality. After the interview data was collected in each session, the audio recordings were then transcribed verbatim into a word document, on a password protected computer, by the primary investigator. The accuracy of the transcribed data 18 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE was verified by the primary investigator by reading the transcripts and comparing them to the original recordings. The transcriptions were then immediately forwarded to two additional therapists (one occupational and one physical therapist) working at Emory Saint Josephs Hospital, who performed data analysis along with the primary investigator. The process of data analysis, which took place immediately after each interview and again after all interviews had occurred, was based on the sequence recommended by Smith et al. (2009) and included the following steps: The primary investigator and colleagues independently read and re-read the transcripts, which were de-identified, using numbers instead of participant names. The primary investigator and colleagues independently made written notes during the reading and re-reading of the transcripts, describing initial interpretations regarding the content, a practice referred to as memoing (Creswell, 2014). In keeping with IPA recommendations the analysts then highlighted emergent themes in the individual interviews by reading over initial notes and identifying concepts, categories, and patterns between comments made (abstraction) (Smith, et al., 2009). This finding of first level concepts and developing categories was also part of the open coding process frequently used in qualitative research (Biddix, 2009). The primary investigator and colleagues then searched in the individual interviews for connections across emergent themes for super-ordinate themes, exploratory comments, and emergent themes (subsumption). This was done by creating written category listings taken from the text of the original transcripts and written on pages of legal pads. To explore the relationships between themes (to garner all the important facets) the process of axial coding was used and allowed the qualitative researchers to expound on, or revise original themes that were 19 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE identified (Biddix, 2009). They looked for opposing relationships between themes (polarization), temporal or cultural themes (contextualization), the frequency of occurrence of emergent themes (numeration), and the positive or negative presentation of themes (function) (Smith, et al., 2009). After individually going through each case to highlight themes (within-case coding), the primary investigator and colleagues moved on to individual analysis of themes across cases (cross-case coding). Therefore, initial themes (open coding) and relationships between themes (axial coding) were identified for both within-case and cross-case coding. Looking at individual participants allowed for deeper understanding of the individual, but looking at multiple participants to find common themes allowed for a deeper understanding of the experience (Ayres, Kavanaugh, & Knafl, 2003). The primary investigator and colleagues performed bracketing (journaling and discussion) throughout the analysis in order to limit possible biases brought out by the data collection and analysis processes (Fischer, 2009). The primary investigator and colleagues then came together to look for patterns across cases by laying out the individual case theme lists and analyzing themes side by side, looking for connections, relationships, and frequency, in a categorizing list format. Re-labeling or re-naming of the themes occurred. This process allowed for triangulation of the data analysis to increase the trustworthiness of findings (Curtin & Fossey, 2007). This step of interpretation, allowed for a deeper analysis of the emergent themes for further interpretation and comparison. By reading the transcripts and going through the process of analysis, while bracketing and discussing the themes with each other, the primary investigator and colleagues were able to follow the double hermeneutic philosophy of IPA. This philosophy involved the analysts gaining their own perspective of the participants opinions of the care they received after LVAD implantation in 20 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE acute care. The benefit of this process is a better understanding and interpretation of the lived experience (Smith, et al., 2009). "Member checking was performed after the initial data analysis via phone contact between each participant and the primary investigator. Member checking is one method by which to increase the trustworthiness of a studys data analysis because it allows for the most accurate presentation of the participants experiences, even after analysis by others (Curtin & Fossey, 2007). During member checks with the participants, the primary investigator described the themes identified in each participants own case and how they were determined. The participants had the opportunity to offer clarification or correction on the findings for better understanding of emergent themes. Member checking was performed with seven participants upon completion of the data analysis and identification of the themes. Member checking could not be performed with two participants, as they could not be reached over the phone and did not return voice messages left on voicemail. Results Themes The findings in this study are presented as themes identified from participants descriptions of their experiences after being implanted with LVADs. Through the analysis of participants descriptions, four major themes emerged from the data: lifestyle change, caregiver support, physiological process, and occupational therapy relevance: hospital to home. The themes are presented below and illustrated by quotations from interview transcripts. Lifestyle Change All participants expressed having experienced a lifestyle change due to an awareness of the LVAD as part of their person, at all times. This new awareness started in the hospital and 21 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE continued through to their life at home. They described the feeling of the bags they were carrying around and the management of the bags. In addition, they discussed use of the equipment at home and when out in the community. One participant stated: ...Its just a, a total new lifestyle. With, you know, maintaining and taking care of all the equipment, making sure that I have my spare battery and chargers with me when I go out. Its, its a new lifestyle that you just have to adapt to. Always having equipment hanging around your neck, around your waist, and remembering to take the spare with you. Another participant remarked: Well, youve got this bag hanging around your neck everywhere you go and its, its 10 pounds, so its, its very heavy. Ive learned how to separate it into two separate bags so that I can distribute the load a little better, but its cumbersome. Its in the way and sleeping the bed with all this equipment, and having to make sure it doesnt fall off as youre turning over. Its harder to find clothes that fit around the drive line and that look decent to go out in public (laughs)you know that its, its just a trial and error thing to, to find out what I can wear and what I cantits just a change. Through the transition from hospital to home, all participants expressed coming to terms with the LVAD as part of getting back to their lives. One study participant said Its with me til death do me part A few participants gave thanks for having the LVAD in order to spend more time with family and live life. Several participants also described moving through the fear and overwhelming knowledge of having the new equipment responsible for their lives. A participant explained I mean I was terrifiedbut now Im okay and thats part of the processgetting to the point where you feel comfortable with your life changeand what you have to do, because it has to be automatic. Another participant said, I was just scaredmy 22 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE wife she was there wit me, and I was like baby are we, we gonna do, be able to do this?It only lasted for a couple of days, and after thatwe were good. As a whole, the participants expressed the importance of regaining their independence with their new LVAD lifestyle. The participants expressed that the teaching and preparation about the use of the LVAD at home was an important part of regaining their independence. One participant, when asked what was meaningful during the hospitalization after the LVAD was implanted said, The teaching processthey taught us how to change our lifestyle and live with the LVAD. To some participants, the teaching involved the LVAD equipment and components, Ah well its a lot to take in all at once swapping batteries and bags, and wall charger to battery and battery to wall chargerstuff that you for sure gotta do. Occupational therapy practitioners were identified as meaningful contributors in providing the teaching and preparation leading to increased independence for the participants, thus assisting the participants and families in their life change. Education regarding function and maintenance of LVAD equipment, exercises, home furniture adaptation, ADLs (specifically the shower process), and use of adaptive equipment in the hospital and then at home were mentioned by all participants. A participant and his spouse described some of the occupational therapy treatments received as, [the occupational therapist] helped you in your daily life, likehow to situate like you get your little table and how to transfer your bags and how to get ready for showerswell I mean its stuff I had to learn... Other participants discussed the occupational therapy teaching in regards to daily living skills: What you all do here is prepare me strength-wise and mentally-wise, as much as you can for going homeyou have to, you know, take care of yourself, have to make that its plugged in, you have to make sure, at night sometimes I have problems with pluggin into 23 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE the cord because theres, I have to go to the bathroom, its plugged in, unplug, plug in, unplug, but, umI realize that and its something Ive accepted by accepting the LVAD in the first place When asked about his experience with occupational therapy in the hospital, another participant stated, [the occupational therapy] got me back on track, as far as getting my dependency, doing for myself, and I think that, that was pretty much needed. As a group, the participants described a positive lifestyle change with the LVAD, expressing happiness with the care received in the hospital and their ability to return home to their lives. Even though they described some difficulty at the start, the education and preparation in the hospital, including that provided by occupational therapy practitioners, was a crucial identified element of the successful transition home to a new life. Caregiver Support Every participant that was interviewed, acknowledged that the caregiver support they received in the hospital and at home was meaningful for them. Caregivers were identified as healthcare professionals, including occupational therapy practitioners, and family members assisting in the care of the patients with LVADs. Family was identified as a big part of the caregiving experience by all participants. Support from family was described as just being there and going through the experience with the participant, to actual physical assistance while in the hospital following LVAD implantation. All but one participant described receiving help from family members of all ages in managing the new LVAD equipment and dressing. One study participant noted, My grandbabies run and get the batteries, they just think thats the most adorable thing to do to take care of mamaw. Other participants discussed family support with daily living skills, either 24 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE basic or instrumental, first in the hospital, then at home. A participant remarked, [my wife] assisted me too with the showerwell she washed my back and you know soaped me up Throughout the interviews, family support was mentioned with appreciation for their help, with some participants acknowledging the added burden to family members now that the participant had received an LVAD. Regarding the effects of the transition from hospital to home, one participant said, I dont think hard for meit might be a little difficult on my wife, cause I was a little bit, you know, I guess babyfied All participants expressed the importance of having family members involved in the training and preparation received from all healthcare professionals, including occupational therapy practitioners, during hospitalization. Characteristics of the healthcare professionals providing caregiver support in the hospital, as reported by the participants included caring, understanding, attentiveness, encouragement, motivation, and patience. One participant said, I went through the surgery and its that they cared, they would give um, advice on the things that I should, you know, I can do to better help myself everyone, every, everyone was helpful. All participants described positive caregiver experiences in the hospital setting, from the ICU to the telemetry floor. One participant stated, I mean actually cried, a cried a couple of times when ah, a couple of nurses I wouldnt see again, because theywere a big impact on meand my recovery. The participants were all able to name nurses, physicians, dietitians, psychologists, LVAD coordinators, therapists, social workers, and even environmental services technicians who assisted them while in the hospital. Seven participants expressed that the therapists or nurses understood the needs of the patients, therefore the patients needed to be open and receptive to what the caregiver was telling them. One participant remarked: 25 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Even though some of your patients, like me, could be grouchy and dont want to do itthinking you know I know how to do this No, let [the healthcare professional] help you, causeyour thing was to get me out of here so I wouldnt come back worse than I was beforeand it helped Occupational therapy practitioners were also identified as positive caregivers by all participants. Caregiving behaviors for occupational therapy practitioners were described by participants as being encouraging, caring, motivating, guiding, and professional. The occupational therapy practitioners caregiving abilities were described in regard to the education or training they provided to the participants, with one commenting: the [occupational therapist] that worked with us was very professional, you know he took his time with us and showed uswhat we need to do, you know, in, in the showers, and a how to take care of this [points to LVAD], um the dos and donts, the cans and cants, because its what motivates [pats the LVAD bag], you know keeps us going, so it was, it very professional Other participants remarked on the general support, consistency, and caring the occupational therapy practitioner provided them. One participant stated: [the occupational therapist] was very positive for me, um, and I hope the rest of the team is like that, and people can feel that because thats what we need, more than, than I think the doctors coming in and telling you everything is alright, is more of a comfort of everyday, and thats what the occupant, occupational therapist, um brings to the table, I feel. Physiological Process 26 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Physical recovery and activity immediately after LVAD implantation was a focus of all participants in the interviews. All participants described the general recovery process immediately after LVAD implantation, particularly when dealing with the successes and frustrations of the body healing. They also described physical activity they performed following surgery and the challenges they faced when trying to become active again. Some participants discussed issues with tape allergies, continued intravenous (IV) medication use, peripherally inserted central catheters, other IV line issues, or body pain. A participant stated: Its a ordeal and for me its a really big one because Im allergic to the adhesive and I have to have it from here on out, trying to keep my skin protected is, is a chore, um, I look like Ive been in a fight and I lost, but on the other hand, you know Im, Ive been told six months and it be good and that this point its getting better Another participant remarked, I had a lot of stuff, um, hooked up to my, hooked up to me, um, I couldnt do a lot of arm, arm exerciseit was more, more of a pushing my little [IV pole]and walking the halls. Other participants acknowledged challenges associated with loss of appetite and adapting sleeping behaviors for the LVAD. One participant stated, So, I had to kinda get myself, make myself, pump myself up to kinda eat, like cause I didnt have a appetite. Physical strength of upper and lower extremities and overall activity endurance were other areas of focus for participants, particularly when getting out of bed. Many described the process of getting up from their bed as particularly challenging because they had to deal with the new equipment, which added weight to their already weakened bodies, and then the lack of strength in the upper and lower limbs making the task more difficult. They described sitting on 27 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE the edge of the bed, moving to the recliner chair, and finally ambulating out into the hall and navigating stairs. One participant described this experience: I was able to go up steps, not like I wanted to, it, you know, before all this got started I was able to run up the steps and run it down. No. Ah, when I go up the steps Im gonna stay up there for a while, when I come down, then I stay downstairs Despite just having undergone surgery, many participants expressed surprise that their bodies could not do more, as they felt better overall than prior to LVAD implantation. A younger participant said Cause I actually thought that I was like Im so ready to get out of bed, Im so ready to do this, but you try to get up and you feel like an old man Almost all participants mentioned occupational therapys role in providing exercise programs to increase strength. Occupational therapy practitioners were seen as teachers providing information on regaining strength, but also motivating the participants to move more and be active with the new LVAD. In addition to strengthening, occupational therapy practitioners were noted as providing activities for range of motion, fine motor coordination, and pain relief. One participant reported [the occupational therapist] had gave me all these things to do my strength with, like the little clay stuff, andtied some stuff to my bed where I can like, do like reps or something [mimicked using theraband attached to bed for arm exercises]. Another participant stated: [the occupational therapist] gave me a sponge and told me to squeeze it, and even though I was squeezing it, I wasnt doing it all the time and the first thing [the occupational therapist] said was see this is why, because actually, um putting the buckles on the bags and doing certain things you really needed the strength in your hands. 28 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Several participants reported neck, body, or shoulder pain and soreness following surgery and while in the hospital. They described how the exercises given by the occupational therapy practitioner helped with pain relief, with one participant saying, with having the shoulder pain, that it can get stiff, so with me doing the exercises, it, it keeps me from having to take the pain medicine to where I can, you know, go about my day. Another participant explained: the first thing [the occupational therapist] taught me, that I loved, was about my neck, because this bag [points to LVAD bag] is so heavy, so [the occupational therapist] had me do the turns and the ups and downs and those things really helped, um because in the beginning it weighs about 10 pounds and you feel itand now its not as bad, and the funny thing is (chuckles), um that when it starts bothering me I start doing those exercises and it still helps. Occupational Therapy Relevance: Hospital to Home As described through the other themes identified above, occupational therapy services played a role in the hospital process of preparing the participants for their new lives and the transition to home. Positive experiences were described, and all participants commented that the guidance and education provided by the occupational therapy practitioners was beneficial, when incorporating the LVAD equipment and accessories (power-based unit, batteries, driveline, controller, bags) into their daily routine. All participants agreed that the occupational therapy services provided in the hospital were applicable to their daily lives and were useful for them once they returned home. When asked their opinion of the applicability of occupational therapy services received in the hospital to their daily life, one participant remarked: Oh absolutely, yeah, ah absolutely. I had to know how to operate my equipment, how to take a shower, and, um, needed to be able to function, um to do my daily routine. [The 29 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE occupational therapist] had goals set up for you and you had to check each one off before you could go. I was able to meet mine Some participants referred to the benefit of occupational therapy as assisting in regaining independence with their basic ADLs, including dressing alternatives and safety. One participant said [The occupational therapist] showed me some good stuff too, how to get my sock on with the puller upper [sock aide] and the grabber thing [reacher] I still need the reacher since Im not supposed to bend over. All participants remembered the shower process with the LVAD and related it as part of occupational therapy experience they had in the hospital. They were all able to give a description of the training required to protect the LVAD and batteries and discuss the precautions for taking a shower. Detailed descriptions for covering the drive line and dressing were given by a few participants. In addition, all participants told of the process of transferring the LVAD controller and batteries from the Go Bag to the Shower bag. Many reported that this change in shower preparation added increased time to the daily routine. One participant noted, Its a bit of an ordeal to have to do all that just to take a shower, but its well worth it. Most participants reported the use of adaptive equipment in the shower (most commonly the shower chair) and the use of a hand held shower for increased ease and independence. The use of these pieces of equipment and having overall larger showers or tub/showers at home, with the shower preparation in the hospital, increased the comfort of the participants once they returned to the home environment. As a group, the participants were effusive in their praise for the first shower taken in the hospital. Comments included, it was wonderful, it was nice to just feel clean again, I felt normal, I was like yes!, and I was fired up. All participants also agreed that it 30 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE was important to experience the actual shower at the hospital prior to going home. One participant expressed the view of a few others, by explaining that the shower taken in the hospital helped in decreasing the anxiety of the shower process, I thought the shower bag was not gonna work and stuff was going to get wet and all that, but after I took the shower I didnt have any more fear. Another participant summarized the importance of the actual hospital shower occurring: thats why its so important to, to get that shower, you, it, it takes away your fear of everything getting wet, it lets you know that hey, you can take a shower, and be okay, and all you have to do is cover thoroughlyits just like the LVAD they tell you all about it, but until you get into it, its still not the same The participants as a whole viewed occupational therapy services and having an actual shower in the hospital as contributing to their success on returning home. All participants considered occupational therapy services a meaningful part of each of the identified themes discussed above lifestyle change, caregiver support, physiological process, and general preparation for home, including the shower process. Discussion Using the interpretative phenomenological approach, this study expounded on prior literature and served as the first qualitative study to explore the patients with LVADs perspectives on the afore-mentioned themes with regard to occupational therapy services in the acute care setting. All participants reported that occupational therapy services meant providing support to patients and families through positive caregiving, involving education and training of LVAD equipment and processes, and including interventions involving physical activity and ADLs, assisting with the new life change (see Appendix F). Through the use of in-depth 31 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE interviews, the results from this study provide an increased understanding of the role occupational therapy plays when caring for patients after they have been implanted with LVADs. Patients with LVADs see occupational therapy practitioners as offering caregiving support through the teaching and physiological interventions they provide, starting in the hospital setting. These occupational therapy interventions and preparations for home, including shower training, were identified as beneficial to those wishing to regain their independence and return home safely after device implantation. Specifically, the participants perspectives provided information regarding occupational therapy interventions they deemed important to helping patients regain their function and return to their lives at home. Participants in the current study, as a whole, identified numerous lifestyle changes they had to undergo as a part of receiving the LVAD. Awareness of surroundings, awareness and maintenance of the equipment, the effect of the equipment on ADLs and sleep, the anxiety of managing the new equipment, home modification, the importance of regaining independence with the LVAD, and the importance of education and preparation for home, were all identified areas of lifestyle change by the participants. The current study findings were consistent with prior literature addressing lifestyle change (Baker et al., 2010; Brouwers et al., 2011; Casida et al., 2011; Casida et al., 2009; Iseler & Hadzic, 2015; Marcuccilli et al., 2014). However, the prior studies were primarily caregiver-reported perceptions and focused mostly on changes that were needed once the participants were at home. The findings of this study add to the prior literature by demonstrating specifically how occupational therapy practitioners assisted the participants while in the hospital, with crucial education regarding the LVAD and its components. This occupational therapy intervention eased the life changes of participants, by letting them and their families know what to expect upon return home. The occupational therapy 32 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE practitioners were able to train the participants and family members regarding the adaptation of ADLs and adaptations within the home environment, facilitating a safe return to independence. Specifically, occupational therapy services addressed management of the LVAD power-based unit and its batteries, use of adaptive equipment for ADLs, alternate clothing choices and safe dressing. A discussion of possible alterations to the home environment and suggestions of furniture for equipment storage and safe maneuvering within the home were also reviewed. Prior qualitative studies have discussed caregivers in regard to caregiver burden following the return home after a patient received a LVAD (Baker et al., 2010; Brouwers et al., 2011; Iseler & Hadzic, 2015). One such study even touched on the importance of hospital caregivers supporting patients and families with the transition home after LVAD implantation (Casida et al., 2011). However, this was again discussed in relation to relieving caregiver burden. Other studies discussed the importance of the interdisciplinary team to support patients and families after LVAD implantation (English & Speed, 2013; Nguyen & Stein, 2013; Shoemaker et al., 2014). However, these studies primarily just named the healthcare team members involved in the care of patients with LVADs, provided a general description of services offered to the patients, or focused on the services provided to the patients and families by the primary researchers discipline, none of which were occupational therapy. In the current study participants corroborated prior research, which focused on the importance of family as caregivers (Baker et al., 2010; Marcuccilli et al., 2014). Family caregiving was described as playing a major role in the successful re-integration of patients with LVADs into their homes and communities. However, building on previous research, this study yields information from the patients perspectives regarding the type of caregiver support, in the hospital setting with collaborative training from occupational therapy practitioners, which is 33 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE meaningful to patients receiving LVADs. In this study, all of the participants stressed the importance of the quality of caregiving and instruction provided by various healthcare providers, in the acute care environment. The participants described the characteristics that the hospital caregivers demonstrated, which led to their added comfort and ability to overcome new challenges presented after LVAD implantation. In addition, the current study provides new information to the LVAD literature regarding the important role that occupational therapy practitioners play as one of the caregivers on the interdisciplinary team. All participants described the positive feelings and experiences the occupational therapy practitioners inspired, along with their effectual characteristics. Guidance with the new LVAD equipment and ADLs, coupled with the consistency of personnel with daily visits, were key factors identified as contributing to a successful occupational therapy experience for the patients, their families, and the occupational therapy practitioners. In addition, participants discussed beneficial interventions provided by occupational therapy services including strengthening, fine motor coordination, range of motion, and home modification and adaptive equipment recommendations, which were important to their new lives. Participant identification of the importance of the occupational therapy caregiver experience provides evidence to support occupational therapy as one of the critical services involved in caring for patients with LVADs, which is in keeping with existing research (Abramson et al., 2012; McIntyre, 2007; Padmanabhan & Thankachan, 2011; Shepherd & Wilding, 2004). Physical activity and the physiological process following LVAD implantation have been addressed in numerous prior studies (Abshire et al., 2014; Ben Gal et al., 2015; Bogaev et al., 2011; Evans et al., 2011; Freeman & Maley, 2013; Hayes et al., 2012; Nicholson & Paz, 2010; Rogers et al., 2010; Shoemaker et al., 2014). Whereas the prior research was primarily 34 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE quantitative and did not report on patients perceptions of physical processes after LVAD placement, the current study adds to this prior knowledge with the addition of new participantreported information. All participants in the current study referenced their physical state while in the hospital. They expressed the importance of mobilization and increasing strength, endurance, and range of motion to enable their independence with the new LVAD and its components. These findings provide additional support to prior quantitative findings (Ben Gal et al., 2015; Bogaev et al., 2011; Evans et al., 2011; Hayes et al., 2012; Rogers et al., 2010), which demonstrated the benefit of exercise following LVAD implantation, by adding the lived experience of the benefits of physical activity, as reported by these patient participants. New information regarding the benefits of exercise and physical activity intervention provided by occupational therapy services, for patients with LVADs, was brought to light by this study. Prior occupational therapy publications included exercise or physical activity as recommendations for possible occupational therapy intervention with these patients (Abramson et al., 2012; McIntyre, 2007; Padmanabhan & Thankachan, 2011; Shepherd & Wilding, 2004). The participant reports in the current study provide evidence to substantiate those recommendations. Occupational therapy exercise and physical activity interventions cited as being beneficial by participants in this study, included range of motion of upper and lower extremities and the neck, fine motor coordination tasks, and upper extremity strengthening with various forms of resistance; the purpose being to assist with the manipulation of the LVAD components, relieve pain, and improve energy levels for increased independence with daily life. Once the participants were able to see the results of these interventions with regard to purposeful activity, they better understood the need for the interventions and were more motivated to perform them. These specific treatments and their purposes support the interventions used with 35 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE the LVAD population in prior occupational therapy publications (Abramson et al., 2012; McIntyre, 2007; Padmanabhan & Thankachan, 2011). Though therapists may be reluctant to use exercise alone, due to its lacking as an occupation-based activity, exercise used therapeutically as a preparatory intervention, can enhance body functions and performance skills, enabling the patients participation in meaningful occupations (AOTA, 2014). The therapeutic exercises described by the participants in the current study are in keeping with the AOTAs (2014), definition of preparatory interventions, improving the motor skills of coordination, manipulation, moves, and endurance, allowing for the patients to manipulate and use the LVAD equipment needed to function in daily life. Prior literature published for occupational therapy practitioners stressed the importance of occupational therapy interventions, including ADLs, when working with patients receiving LVADs (Abramson et al., 2012; McIntyre, 2007; Padmanabhan & Thankachan, 2011; Shepherd & Wilding, 2004). In addition, Casida et al. (2011) reported that caregivers of patients with LVADs described that ADLs required a lot of adjustment following implantation and the return home. The current study supports prior literature, with positive descriptions from patients regarding their experience with working on their ADLS and developing new performance patterns with occupational therapy in the hospital setting. Participants described the beneficial education provided by occupational therapy practitioners, developing new routines and habits to use adaptive equipment for dressing and showering, in order to reach lower body parts and for safety. This is similar to interventions described in prior occupational therapy publications (McIntyre, 2007; Padmanabhan & Thankachan, 2011; Shepherd & Wilding, 2004). The current study demonstrated that the participants highly valued being able to participate in a real shower while they were in the hospital, as opposed to a simulated shower or 36 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE sponge bathing, because it allowed them to better transfer the skill to their home environment. This is new information from the patient-perspective that supports prior occupational therapy literature recommending an actual shower in the healthcare facility, in order to prepare patients for a safe transition home (Padmanabhan & Thankachan, 2011; Shepherd & Wilding, 2004). Participants in the current study gave descriptions of the shower process similar to that provided by Padmanabhan and Thankachan (2011), including the coverage of the dressing and use of the shower bag to protect the LVAD components. The new discovery of the importance of the actual shower in the hospital for adequate preparation to return to ADL occupations within the home, and for reducing concerns regarding protection of the LVAD and dressing when wet, provides evidence to support the interventions described by prior occupational therapy literature (Padmanabhan & Thankachan, 2011; Shepherd & Wilding, 2004). Limitations Although the participants in this study provided an in-depth look into their experiences in the hospital with occupational therapy services, following their LVAD implantation, the sample consisted of patients recruited from a single medical center, limiting the generalizability to other recipients of LVADs. Study participants responded to questions about their experiences in the hospital following LVAD implantation and their interaction with occupational therapy in a single interview. An attempt was made to limit the effects of memory by including only participants who had received LVADs within the last six months. However, these retrospective accounts were dependent on participants memories of the activities in the hospital and any issues that these individuals were experiencing at the time of interview. Participant responses could also be skewed toward positive responses, given that the primary investigator was identified as an 37 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE occupational therapy practitioner and represented the rehabilitation department from which the participants received services. (Though it should be noted that the primary investigator was not involved in the care of any of the participants who were interviewed.) Implications for Practice and Future Research Despite the limitations listed above, the findings of the present study begin to bridge the gap of knowledge on the meaning of occupational therapy services for patients with LVADs in the acute care setting. These study findings demonstrate the need for occupational therapy intervention in the hospital setting to include beneficial patient and family education, strengthening, fine motor coordination, range of motion, home modification recommendations, and adaptive equipment recommendations, when working with patients receiving LVADs. These interventions, addressing body functions and improving performance motor skills, or assisting in the creation of new performance patterns, allow patients with LVADs to return to their meaningful occupations of health management and maintenance, and ADLs using the LVAD equipment and accessories. Participant reporting in this study demonstrates the need for occupational therapy practitioners to work with patients with LVADs, in order to address ADLs (and specifically to perform actual showers) prior to discharge home, for improved patient preparation and independence. Further empirical research is warranted to examine the effectiveness of occupational therapy interventions in general. In particular, studies comparing the outcomes for those receiving showers prior to discharge from the hospital, versus those only simulating the shower process would help understanding of patients needs and abilities post LVAD implantation. Accordingly, it would be beneficial for the experience of patients with LVADs 38 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE who did not receive an actual shower in the acute care setting prior to discharging home to be further understood from a qualitative perspective. In addition, further research into the benefit of home health occupational therapy services, to aid the transition from hospital to home, is needed to inform occupational therapy practitioners of long-term management needs for patients post LVAD implantation. Future research comparing drive-line dressing infection rates for those receiving shower training versus those that do not could be useful in possibly decreasing hospital readmission rates for individuals with LVADs. Future research could also be performed with retrospective analyses of patients with LVADs who received occupational therapy services versus those that did not and the effects on length of stay and readmission rates. From a patient perspective, the study shows that occupational therapy is an important part of the interdisciplinary team, working with patients with LVADs early after implantation. Occupational therapy governing organizations, education programs, students, and practitioners should be aware of this growing patient population and the specific occupational therapy services that can be offered to support them. Conclusion This study addresses the lack of knowledge regarding the experience of patients with LVADs, who have received occupational therapy services as part of their hospitalization, post implantation. The study expands our understanding of the processes and preparations required to ensure a successful return home for these patients. LVAD implantation is a significant, life changing event affecting patients body functions and performance skills. Lifestyle changes are required following LVAD implantation, and the education and training prior to discharge from the hospital, including that provided by occupational therapy practitioners, are important pieces in the journey of getting back to daily occupations. 39 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE These study participants identified occupational therapy practitioners as an important member of the caregiver and interdisciplinary team, serving patients receiving LVADs and preparing them for the changing performance patterns of their lives. The study also highlights the patient-perceived, beneficial interventions provided by occupational therapy services in the acute care environment. Occupational therapy practitioners, educators, and students can use this information to recognize and anticipate the challenges experienced by patients receiving LVADs. An increased awareness of the LVAD experience will allow for quality patient-centered care and improved outcomes for these patients going forward. 40 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE References Abramson, M., Harvey, J., Greenfield, M., Lauman, S., & Metzler, D. (2012). A case study of OT intervention for a recipient of a left ventricular assist device. Advance Healthcare Network for Occupational Therapy Practitioners, 28(16), 16. Abshire, M., Dennison Himmelfarb, C. R., & Russell, S. D. (2014). Functional status in left ventricular assist device-supported patients: A literature review. Journal of Cardiac Failure, 20(12), 973-983. Alsara, O., Reeves, R. K., Pyfferoen, M. D., Trenary, T. L., Engen, D. J., Vitse, M. L., Perez Terzic, C. M. (2014). Inpatient rehabilitation outcomes for patients receiving left ventricular assist device. American Journal of Physical Medicine and Rehabilitation, 93(10), 860-868. American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1), S1S48. http://dx.doi.org/10.5014/ajot.2014.682006 American Occupational Therapy Association. (2014). Scope of Practice. Retrieved from: http://ajot.aota.org/article.aspx?articleid=1934867 Ayres, L., Kavanaugh, K., & Knafl, K. (2003). Within-case and across-case approaches to qualitative data analysis. Qualitative Health Research 13(6), 871-883. Baker, K., Flattery, M., Salyer, J., Haugh, K., & Maltby, M. (2010). Caregiving for patients requiring left ventricular assistance device support. Heart & Lung, 39(3), 196-200. Ben Gal, T., Piepoli, M. F., Corra, U., Conraads, V., Adamopoulos, S., Agostoni, P., Jaarsma, T. (2015). Exercise programs for LVAD supported patients: A snapshot from the esc affiliated countries. International Journal of Cardiology, 201, 215-219. 41 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Biddix, J. (2009, July 19). Qualitative coding & analysis. Research Rundown. Retrieved from https://researchrundowns.com/qual/qualitative-coding-analysis/ Bogaev, R. C., Pamboukian, S. V., Moore, S. A., Chen, L., John, R., Boyle, A. J., Frazier, O. H. (2011). Comparison of outcomes in women versus men using a continuous-flow left ventricular assist device as bridge to transplantation. The Journal of Heart and Lung Transplantation, 30(5), 515-522. Brouwers, C., Denollet, J., de Jonge, N., Caliskan, K., Kealy, J., & Pedersen, S. S. (2011). Patient-reported outcomes in left ventricular assist device therapy: A systematic review and recommendations for clinical research and practice. Circulation: Heart Failure, 4, 714-723. Buck, L. A. (1998). Physical therapy management of three patients following left ventricular assist device implantation: A case report. Cardiopulmonary Physical Therapy 9(2), 8-14. Casida, J. (2005). The lived experience of spouses of patients with a left ventricular assist device before heart transplantation. American Journal of Critical Care, 14(2), 145-151. Casida, J., Peters, R., & Magnan, M. (2009). Self-care demands of persons living with an implantable left-ventricular assist device. Research & Theory for Nursing Practice, 23(4), 279-293. Casida, J. M., Marcuccilli, L., Peters, R. M., & Wright, S. (2011). Lifestyle adjustments of adults with long-term implantable left ventricular assist devices: A phenomenologic inquiry. Heart & Lung, 40(6), 511-520. Chu, S. K., McCormick, Z., Hwang, S., Sliwa, J. A., & Rydberg, L. (2014). Outcomes of acute inpatient rehabilitation of patients with left ventricular assist devices. American Academy of Physical Medicine and Rehabilitation, 6, 1008-1012. 42 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Creswell, J. (2014). Research design: Qualitative, quantitative, and mixed methods approaches. (4th ed.). Thousand Oaks, CA: SAGE. Curtin, M., & Fossey, E. (2007). Appraising the trustworthiness of qualitative studies: Guidelines for occupational therapists. Australian Occupational Therapy Journal, 54, 88-94. English, M. L., & Speed, J. (2013). Effectiveness of acute inpatient rehabilitation after left ventricular assist device placement. American Journal of Physical Medicine and Rehabilitation, 92, 621-626. Evans, J., Tsekouras, C., Johnson, K., & Marx, M. (2011). Effect of early mobilization efforts on post-operative length of stay after cardiac transplant and left ventricular assist device surgery. Critical Care Nurse, 31(2), 50-51. Fernandez, N., & Ford, K. (2014). Early progressive mobilization and physical therapy management in a patient with a total artificial heart device. Cardiopulmonary Physical Therapy Journal, 25(1), 23-28. Fischer, C. (2009). Bracketing in qualitative research: Conceptual and practical matters. Psychotherapy Research, 19(4-5), 583-590. Freeman, R., & Maley, K. (2013). Mobilization of intensive care cardiac surgery patients on mechanical circulatory support. Critical Care Nursing Quarterly, 36(1), 73-88. Hayes, K., Leet, A. S., Bradley, S. J., & Holland, A. E. (2012). Effects of exercise training on exercise capacity and quality of life in patients with a left ventricular assist device: A preliminary randomized controlled trial. The Journal of Heart and Lung Transplantation, 31(7), 729-734. Hollander, S. A., Hollander, A. J., Rizzuto, S., Reinhartz, O., Maeda, K., & Rosenthal, D. N. (2014). An inpatient rehabilitation program utilizing standardized care pathways after 43 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE paracorporeal ventricular assist device placement in children. The Journal of Heart and Lung Transplantation, 33, 587-592. Humphrey, R., Buck, L., Cahalin, L., & Morrone, T. (1998). Physical therapy assessment and intervention for patients with left ventricular assist devices. Cardiopulmonary Physical Therapy Journal, 9(2), 3-7. Iseler, J., & Hadzic, K. G. (2015). Developing a kit and video to standardize changes of left ventricular assist device dressings. Progress in Transplantation, 25(3), 224-229. Lietz, K. (2010). Destination therapy: Patient selection and current outcomes. Journal of Cardiac Surgery, 25, 462-471. Marcuccilli, L., Casida, J., Bakas, T., & Pagani, F. D. (2014). Family caregivers inside perspectives: Caring for an adult with a left ventricular assist device as a destination therapy. Progress in Transplantation, 24(4), 332-340. McGarrigle, L., & Caunt, J. (2016). Physical therapist-led ambulatory rehabilitation for patients receiving centrimag short-term ventricular assist device support: Retrospective case series. Physical therapy, 96(12). McIntyre, M. (2007). Keeping vad patients functional: OTs bring unique skills when working with patients with ventricular assist devices. Advance Healthcare Network for Occupational Therapy Practitioners, 23(5), 43. Murray, M. A., Osaki, S., Edwards, N. M., Johnson, M. R., Bobadilla, J. L., Gordon, E. A., Kohmoto, T. (2009). Multidisciplinary approach decreases length of stay and reduces cost for ventricular assist device therapy. Interactive CardioVascular and Thoracic Surgery, 8, 84-88. 44 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Nguyen, E., & Stein, J. (2013). Functional outcomes of adults with left ventricular assist devices receiving inpatient rehabilitation. American Academy of Physical Medicine and Rehabilitation, 5, 99-103. Nicholson, C., & Paz, J. (2010). Total artificial heart and physical therapy management. Cardiopulmonary Physical Therapy Journal, 21(2), 13-21. Nissinoff, J., Tian, F., Therattil, M., Salvarrey, R. M., & Lee, S. W. (2011). Acute inpatient rehabilitation after left ventricular assist device implantation for congestive heart failure. PM&R: The Journal of Injury, Function, and Rehabilitation, 3(6), 586-589. Norton, D., Kuhar, S., & Poduri, K. R. (2015). Functional outcomes in patients with a left ventricular assist device. Journal of Physical Medicine, Rehabilitation, & Disabilities, 1(007), 1-5. Padmanabhan, K., & Thankachan, S. (2011). Occupational therapy in cardiac care: Left ventricular assistive devices. OT Practice, 15-20. Perme, C., Southard, R., Joyce, D., Noon, G., & Loebe, M. (2006). Early mobilization of LVAD recipients who require prolonged mechanical ventilation. Texas Heart Institute Journal/From The Texas Heart Institute of St. Lukes Episcopal Hospital, Texas Childrens Hospital, 33(2), 130-133. Rogers, J. G., Aaronson, K. D., Boyle, A. J., Russell, S. D., Milano, C. A., Pagani, F. D., Slaughter, M. S. (2010). Continuous flow left ventricular assist device improves functional capacity and quality of life of advanced heart failure patients. Journal of the American College of Cardiology, 55(17), 1826-1834. Shepherd, J., & Wilding, C. (2006). Occupational therapy for people with ventricular assist devices. Australian Occupational Therapy Journal, 53, 47-49. 45 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Shoemaker, M. J., Gaskell, A., VandeBunte, K., Sefton, D., McLeod, J., Karia, D. H., Khaghani, A. (2014). Early ambulation predicts length of stay and discharge location following left ventricular assist device implantation. Cardiopulmonary Physical Therapy Journal, 25(3), 75-84. Slaughter, M. S., Pagani, F. D., McGee, E. C., Birks, E. J., Cotts, W. G., Gregoric, I., ... & Acker, M. A. (2013). HeartWare ventricular assist system for bridge to transplant: Combined results of the bridge to transplant and continued access protocol trial. The Journal of Heart and Lung Transplantation, 32(7), 675-683. Smith, J., Flowers, P., & Larkin, M. (2009). Interpretative phenomenological analysis: Theory, method and research. London, U.K.: SAGE. Stewart, G. C. & Givertz, M. M. (2012). Advances in mechanical circulatory support: Mechanical circulatory support for advanced heart failure: Patients and technology in evolution. Circulation, 125, 1304-1315. Van Manen, M. (1990). Researching lived experience: Human science for an action sensitive pedagogy. London, Ontario: Althouse Press, Faculty of Education, University of Western Ontario. Yost, G., Coyle, L., Milkevitch, K., Adair, R., Tatooles, A., & Bhat, G. (2017). Efficacy of inpatient rehabilitation after left ventricular assist device implantation. Physical Medicine & Rehabilitation Journal, 9(1), 40-45. 46 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Appendix A RESEARCH PARTICIPANTS NEEDED Have you or an immediate family member been implanted with a LVAD in the last 6 months? We are conducting a study about persons with LVADs perceptions of the care they received following LVAD placement. In particular we are looking for persons with LVADs views about the occupational therapy they received while in the hospital. As a participant in the study, you will be asked to participate in: A 45-90 minute face-to-face, audio recorded interview, directly after a Heart Failure Clinic visit. Elizabeth Wyble, OTR/L and Doctoral Student in Health Sciences will be conducting this study. If you are interested in participating or have more questions, please notify your LVAD nurse/coordinator or contact Elizabeth at (678) 843-5791 to confirm eligibility for the research. This study is being conducted in collaboration with Emory Saint Josephs Hospital and the University of Indianapolis. This study has been approved by the Emory Saint Josephs Hospital and University of Indianapolis Institutional Review Boards, study # 051-16-2. Your personal information will be kept confidential. 47 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Appendix B Consent for Primary Investigator Contact One of the occupational therapists at Emory Saint Josephs Hospital is performing a study regarding patients with LVADs. She is looking for participants. If you are interested in participating, please provide your contact information below and sign to provide your consent for her to contact you. We will pass your contact information onto her by way of a phone call. Your participation is voluntary and is not a requirement for your continued treatment at the Emory Saint Josephs Heart Failure Clinic. Name: ______________________________________________________ Address: ____________________________________________________ ___________________________________________________________ Phone Number: ______________________________________________ Email: ______________________________________________________ _______________________________ Print Name _______________________________ _________________________ Signature Date 48 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Appendix C Institutional Review Board of Emory Saint Josephs Hospital Consent Form to Participate In Research (Do Not Sign Unless You Have Read The Document And Are In The Presence Of The Primary Investigator). Study Title: What is the Meaning of Occupational Therapy for Patients Receiving a Left Ventricular Assist Device in the Acute Care Setting? Principal Investigators: Elizabeth Wyble, OTR/L Experts/Colleagues: Lisa Borrero, PhD., Jennifer Fogo, PhD, OTR, Cheryl Bittel, MSN, APRN-CCNS, NP-C, CCRN, Katie Caldwell, MS, OTR/L, Deborah Mann, BS, PT I. Introduction to Participate: You are being invited to participate in the study titled What is the Meaning of Occupational Therapy for Patients Receiving a Left Ventricular Assist Device in the Acute Care Setting? because: You have received a left ventricular assist device (LVAD) in the last six months Received occupational therapy during your hospitalization at Emory Saint Josephs Hospital Occupational therapy (OT) is commonly received post-operatively after LVAD placement, in the hospital setting. The goal of the OT is to improve functional independence with daily living skills in preparation for return to the home and community for the patient receiving a LVAD. The investigators know that OT is provided to each patient, but the experiences of each patient are different. Therefore the goal of the current study is to determine the meaning of occupational therapy for those implanted with a left ventricular assist device. The research is being conducted by Elizabeth Wyble, OTR/L in coordination with Katie Caldwell, MS, OTR/L, Deborah Mann, BS, PT, and Cheryl Bittel, MSN, APRN-CCNS, NP-C, CCRN at Emory Saint Josephs Hospital and in coordination with Lisa Borrero, PhD. and Jennifer Fogo, PhD, OTR at the University of Indianapolis. More information about the research study can be received from the principal research investigator. II. Research Study Description To participate you will be asked to provide a signature of agreement to determine if you will take part in a private, audio recorded, interview session of approximately 45-90 minutes. You will be asked questions regarding your hospitalization after your LVAD was implanted. III. Risks There is no identified risk by participating in the study. 49 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE IV. Voluntary Participation and Withdrawal Your decision as to whether to participate in this Research Study is entirely voluntary and you are under no obligation to consent or participate in this Research Study. If you choose to participate in this Research Study, you have the right to withdraw from participation at any time for any reason. Your decision not to participate or to withdraw from participation will not result in any penalty to you, loss of benefits to which you are otherwise entitled, or adversely affect your access to health care or treatment by your physician, nurse, or therapist. You may ask questions about the Research Study at any time. You may receive information about your rights as a research participant from the Institutional Review Board (IRB) of Emory Saint Josephs Hospital of Atlanta, Inc. at (678) 843-7767. The investigator may withdraw you from the study at any time. V. Benefit(s) No benefit from your participation is guaranteed. The results of the Research Study may help to improve patients care after LVAD implantation, in the hospital setting. VI. Compensation You will not receive payment and/or compensation for participating in this Research Study. Information about any research related risks can be received from the principal investigator. CONFIDENTIALLITY AND AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATION Any information obtained as a result of your participation in this research will be kept as confidential as legally possible. A copy of your signed Research Consent form and the Study data will be subject to Emory Saint Josephs Hospital confidentiality policies. Federal law requires that your privacy, security, and unauthorized access to your health information will be protected. You may change your mind and revoke (take back or withdraw) this Authorization at any time and for any reasons. To revoke this Authorization, you must write to: Elizabeth Wyble, OTR/L, Rehabilitation Services Department, Emory Saint Josephs Hospital, 5665 Peachtree Dunwoody Rd., NE, 5th Floor, Room 5C, Atlanta, GA 30342. However, if you revoke this Authorization, the researchers and other parties listed may continue to use and disclose the information they previously collected as permitted by the Informed Consent Form. Information that has already been de-identified cannot be taken back. To maintain the integrity of this Research Study, you generally will not have access to results related to this research until the Study is complete. If all other information that does not or can identify you is removed from your health information, the remaining information will no longer be subject to this Authorization and may be used or disclosed for other purpose. 50 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Your health information will be used or disclosed when required by law. If you have questions about the use of your information, you can call Elizabeth Wyble, OTR/L at (678) 843-5791 or the Emory Saint Josephs Hospital Privacy Officer at (404) 778-2757. This Authorization does not have an expiration (ending) date. You will be given a copy of this Authorization after you have signed it. _______________________________ ________________________________ Signature of Participant Date _______________________________ ________________________________ Signature of Person Obtaining Consent Date I hereby acknowledge that the informed consent process has been completed prior to initializing any research procedures. _______________________________ ________________________________ Signature of Investigator Date _______________________________ Print Name of Investigator 51 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Appendix D Interview Questions 1. What was your experience in the hospital after your LVAD was implanted? 2. What was or was not meaningful to you during your hospital stay after your LVAD was implanted? 3. What was your experience upon returning home after your LVAD was implanted? 4. What was your experience with occupational therapy in the hospital? 5. What is your opinion of the applicability of the occupational therapy you received to your daily life? 6. What was your experience when showering with the LVAD in the hospital? 7. What was the difference between showering in the hospital versus at home? Probing or clarification questions: 1) Could you say more about that? 2) Could you explain that further? 3) Are you talking about or do you mean _____? 4) Could you talk more about _____? 52 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Appendix E Characteristics of Participants in Study Table 1 Characteristics of Participants in Study Participant Age Marital Status Sex Race Reason for LVAD Type of LVAD Time with LVAD 1 56 Single F Black DT HeartWare 106 days 2 47 Married M Black BTT HeartWare 68 days 3 45 Married M Black DT HeartMateII 120 days 4 70 Married M Black DT HeartWare 124 days 5 70 Married F White DT HeartWare 131 days 6 19 Single M Black BTT HeartWare 155 days 7 78 Widow F White DT HeartMateII 22 days 8 50 Married M White BTT HeartWare 27 days 9 31 Married F Black BTT HeartWare 15 days Abbreviations: F, female; M, male; DT, destination therapy; BTT, bridge to transplant; LVAD, left ventricular assist device. 53 OCCUPATIONAL THERAPY AND VENTRICULAR ASSIST DEVICE Appendix F The Meaning of Occupational Therapy for Patients with Left Ventricular Assist Devices Facilitating Life Change: Hospital to Home Educator and Guide Physical Activity Occupational Therapy Caregiver: Support Motivation Encouragment Activities of Daily Living *Shower Figure 1. The meaning of occupational therapy (OT) for patients with left ventricular assist devices (LVADs). Demonstrates the different services provided by OT (and their relationship to each other) that assist patients with LVADs affect successful life change after implantation.  ...

... Welcome to Fallen Crest: An Interconnected Collection of Short Stories on Children of Divorce By Jessica Tillman An Honors Project submitted to the University of Indianapolis Strain Honors College in partial fulfillment of the requirements for a Baccalaureate degree with distinction. Written under the direction of Professor Kevin McKelvey. April 16, 2016 Approved by: _______________________________________________________________________ Professor Kevin McKelvey, Faculty Advisor _______________________________________________________________________ Dr. James B. Williams, Interim Executive Director, Strain Honors College ________ _______________________________________________________________ First Reader _______________________________________________________________________ Second Reader J. Tillman 1 Abstract Welcome to Fallen Crest is an interconnected collection of short stories that follows three children, siblings Charlotte Charly and twins Robert and Louis Louie Stephens over the course of eight years as they grow up with divorced parents, Amanda and Edward Ed. Each child reacts differently to each situation they come across, whether it be new relationships for their parents (Ed gets back together with his college girlfriend Tasha), or the complications of growing up (Robert and Louie growing apart as they get older despite the fact that they were extremely close as kids). The goal of this collection is to provide more literature for young adults experiencing divorce situations and to let them know that they are not alone in their experiences with divorced parents. There is always comfort in knowing that someone is not alone, even if they feel so, like many children can feel after a divorce. This collection is also for parents to try and understand what their child might be thinking while going through these experiences as they themselves go through their own difficulties of raising children on their own. J. Tillman 2 Acknowledgements Dedicated to my mother Julie and brother Spencer, who experienced these events first hand and never backed down from a challenge Special thanks to Zachary Lee and Dani McCormick for reading every single draft of these stories, answering all of my questions at any time during the day, and being a source of comfort through the stress and chaos that was this project. Another special thanks goes out to my advisor Professor Kevin McKelvey for helping me with my undergraduate career of writing and editing, giving me the courage to write about my own relationship with my father, as well as pushing me to do this project to expand my knowledge as a writer. I am forever in your debt. Finally, to Francesca Zappia and Professor Kitty Flowers. My introduction to creative writing here at the university would not have been the same without you two. May your writings and teachings continue on to inspire more students to write. J. Tillman 3 Table of Contents Abstract1 Acknowledgement...2 Table of Contents.3 Statement of Purpose.......4 Introduction..5 Procedure.6 Analysis/Conclusion..12 Reflection...14 References..15 Appendices.16 A Product Produced....16 Welcome to Fallen Crest16 Water Hazard.....41 Scars...57 Cash for a Wedding...73 Text Messaging..84 B Story Development........103 Welcome to Fallen Crest Outline.....103 Character Age Sheet128 Character development sheets..129 C Annotated Bibliography.159 J. Tillman 4 Statement of Purpose In this project, I composed a collection of short stories centered around the conflicts that children of divorce can experience. The main character, Charly, spends eight years growing up as the eldest of three with divorced parents,taking on the roles of both child and parent for her younger twin brothers Robert and Louie. One of these short stories had originally been written for the English Capstone project with the help of Dr. Robisch and Professor McKelvey, but has been heavily edited over the course of this project. The other four stories were written specifically for this project. While this collection means a lot to me, in part for being a larger collection of stories and because I am a child of divorce, it posed the challenge of separating myself and my own experiences from Charlys. I wanted readers experience first hand what children of divorce can experience in reality. Through Charly and her twin brothers, I have been able to create unique characters who portray real children growing up in various divorce situations. I have read authors who have written series of interconnected short stories to help develop my skills at connecting stories together while also having each story stand on its own instead of being read all at once like a novel. Some examples of authors I read were Sherwood Anderson, Julie Autumn List, Claire Vaye Watkins, and Flannery OConnor. I also read Janet Burroway to learn and understand more about the craft of creative writing. J. Tillman 5 Introduction Writing has always been a part of who I am as a person. I have constantly found myself reading books and writing stories that surprised even me. My writing seemed different from many published authors because it is brutal and honest about divorce situations and how it can be both good and bad for the children and the parents. Expanded families are almost never written about, and even if they are, they are only mentioned as a problem point for the main character to push on with their own story, whether it be getting the boy of their dreams to take them to prom or falling into another world where the main character has to save the countryside from tyranny, instead of being a fully developed character the protagonist can interact with. I wanted this collection to contribute to the small and almost nonexistent section of literature about divorce families and to have an impact on the people who read the collection to understand more about these situations and what goes on for both parties involved as well as those who are thrown into the mix years later, such as stepfamily and halfsiblings. J. Tillman 6 Procedure While writing this collection of short stories, I kept in mind a few topics I wanted to focus on and develop over the course of this project.. One of these topics was the overall creative writing experience of this project. These were fictional stories and I wanted to remove myself as the main character going through these events myself and become the narrator. I also wanted to write in a different genre then I was comfortable in to expand my knowledge of how to write and what differences there were between genres. Another topic I kept in mind was the craft that goes into writing stories to help develop varied sentences and story structures to keep readers engaged from the beginning to the end of each story and the collection as a whole. The final topic was the focus on the children of divorce and having the characters become real and accurate representations of what other children experience. The children had stories to tell and I told them as best I could without my personal bias getting in the way. The first challenge I faced with this project was whether to write these characters into a novel or a collection of short stories as each posed their own unique difficulties. Professor McKelvey, my advisor, and I decided on a short story collection for various reasons. One aspect of short stories that I have struggled with my whole writing career is creating a definite ending without extra information added or unnecessary details remaining in the stories themselves that could question a potential ending. Each story needs to have a definitive beginning, middle, and end with each word chosen carefully to make the most impact. Janet Burroway states, [Short stories] can deal with only one or a very few consciousnessesIt can afford no digression that does not directly affect the J. Tillman 7 action (52). I needed to learn how to end each story and use words wisely, thus choosing a collection of interconnected short stories instead of writing a novel, which would allow for me to expand beyond the story itself and leave in those unnecessary details that would take away from the story instead of helping it. Another reason for choosing short stories over an entire novel is because multiple viewpoints and perspectives can be used to show how other characters feel in a particular situation or how the characters look from a removed point of view, instead of an upclose bias the character has about themselves. With a novel, it follows one character over time and can change how characters look or come across from a limited viewpoint that might not give the whole picture like an interconnected collection of short stories with different perspectives can accomplish. This limits the author to a single, consistent perspective while short stories can break up the singularity and allow the author to write the same story from many different angles to provide the readers with a more complete picture of the situation. Writing is an activity that many people find themselves doing, either on the side as a hobby if it isnt a full time job. However, there are several thoughts and ideas that go into writing beyond putting down words on a page and hoping they make something worth reading. Natalie Goldberg writes in her craft book Writing Down the Bones : This is the practice school of writing. Like running, the more you do it, the better you get at it. Some days you dont want to run and you resist every step of the three miles, but you dont wait around for inspiration and deep desire to runThats how writing is too. Once youre deep into it, you wonder what took J. Tillman 8 you so long to finally settle down at the desk. Through practice, you actually do get better. You learn to trust yourself more and not give in to your voice that wants to avoid writing (11). Though I had trouble being motivated for this project some days, because the subject was a rough one for me to get through, I wrote every day without sudden inspiration for a character or situation. Goldbergs model sets an important structure that helped me considerably in developing my writing as well as sticking to guidelines and getting things done on a regular pace that I have never been able to do at a consistent rate. I wrote and edited the five stories in the collection in three months, and with a short timeframe, using this model kept me on track to meet the deadline with a completed project instead of pieces of a single story had I waited for inspiration to help write these stories. Connecting stories became increasingly difficult the further I got into the writing process. One thing I kept in mind was that each story had its own story plot along with the whole collections story arch. Susan Mann stated that the protagonist will start at a child's level of understand of the particular situation before developing into a kind of adult by the end of each story (9). Since I began to write in high school as well as in college at the University of Indianapolis, I have always been taught that the protagonist should go through a change over the course of the story not only to show character development but also to show growth. Characters must be challenged in various ways, not only in a single short story with a distinct beginning, middle, and end, but also over J. Tillman 9 the course of the whole collection to see how the characters change from the very beginning to the last moment before the collection ends. Not only is connecting these stories together important, but the characters must be precise. It is said that authors should know their characters better than their best friends by getting into the characters minds and understanding what their motives, inspirations, and demands are. Stephen King mentioned this in his memoir, On Writing : I never got to like Carrie White and I never trusted Sue Snells motives for sending her boyfriend to prom with her, but I did have something thereThe most important [part of understanding Carrie] is that the writers original perception of the charactermay be as erroneous as the readers. Running a close second was the realization that stopping a piece of work just because its hard, either emotionally or imaginatively, is a bad idea. Sometimes you have to go on when you dont feel like it, and sometimes youre doing good work when it feels like all youre managing is to shovel shit from a sitting position (77). Characterization was difficult for me because each character had a real life counterpart that they were based on. While creating these characters, certain aspects of those real people came out, helping me to understand how the characters worked together and acted when they were alone or had company. I used the idea Stephen King mentioned above and based characters on my family and extended family, to create the best environment for this particular collection of short stories and give them a authenticity to the situation as well as the emotions that the characters display throughout the stories. J. Tillman 10 Even though basing a character on myself or others can be a great starting point, it can draw on a more memoiresque style of writing I wanted to stay away from. I already wrote a creative nonfiction essay in this style that inspired this project and I needed something new to write to expand my writing abilities and interests. This became my biggest concern while writing. I returned to Janet Burroway, who commented on this particular dilemma in her book Writing Fiction: A Guide to Narrative Craft : If the character is based on you or someone you know, drastically alter the model in some external way: Change blond to dark or thin to thick imagine the character as the opposite gender or radically alter the setting in which the character must act. Part of the trouble with writing directly from experience is that you know too much about itwhat they did, how you felt (143). Though this is a practice I dont use in my writing, I used my own knowledge about divorce situations with my characters to make it more realistic instead of sounding like a collection of stories that tried to be accurate but lacked a certain understanding of divorce situations and how they can affect people. This seemed to be the biggest problem I found when reading novels with divorce mentioned as a situation for the main characters. There needed to be meaning behind the stories and changing the characters from their real life counterparts to fictional fleshed out characters would create a fictional story over a memoir. The biggest concept I kept in mind for this collection of stories was the theme. Themeis not imposed on the story but evoked from within itinitially from intuitive by finally an intellectual act on the part of the writer (Burroway 26). This is from an J. Tillman 11 excerpt from John Gardner in his book The Art of Fiction: Notes on Craft for Young Writers republished in Janet Burroways Writing Fiction: A Guide to Narrative Craft . This is a key elements that writers keep in mind about writing overall, and particularly in my own collection. Since divorce was a heavy subject that was also the main focus of the stories, actions and reactions from characters needed to make logical sense over a long period of time eight years. Because of this, the collection is coming of age stories, adding depth to the theme and the characteristics of the stories individually as well as a whole. This pulls in the sociology and psychology books I read about children of divorce to see how they react at different ages and have my characters do something similar to add to the credibility of the characters and the situations I created. It was important to see what traits most children of divorce had in common at different ages to make the characters relatable in their actions and emotions. J. Tillman 12 Analysis and Conclusion For this project, the main goal was to create a collection of stories that show that children are not alone in their strange and sometimes scary experiences when it comes to divorce. Everyone goes through a different event, but this collection shows how dramatic things can be and any situation that the main character Charly and her brothers go through they can overcome. It may sound optimistic, but it is better to be optimistic than pessimistic. If children focus on the depressing events they experience, a small hope they may have, such as making a new friend or waking up in the morning, will not be acknowledged. It is these little events that help to make a day better and this collection shows that in the best way possible. Since Young Adult literature is a large section in the publishing industry based on bookstore and library sections, it seems to be a lack of insight from the publishing industry to not include more stories for children about divorce. The absence of a strong body of literature about children of divorce indicates a lack of attention to the needs of such children. Having gone through my own experiences, having to help myself and being alone made life more difficult without literature to help me know that I was not experiencing divorce on my own. Because of this learned skill of needing to be able to do things by myself, it became difficult for me to accept help from others. But young adults do not have to go through these experiences alone anymore. There are others who know what it feels like to be alone and they should not have to feel that way. These stories fill the lack of divorce literature in the young adult genre. J. Tillman 13 Even though there are five stories in this particular collection, many characters were left out in favor of focusing on the characters established in the collection. For the continuation of the story of Charly and her twin brothers, more stories will be written to fill in the various holes in the timeline that were skipped over in order to focus on the most important stories in the collection. J. Tillman 14 Reflection This collection of stories was difficult to write and edit. Since the stories were about children of divorce, I wanted to understand the emotion that the characters would have at each stage of their lives, I needed to remember my own experiences and that brought up some memories and emotions I had not experienced for a while. Because of this, it became harder every day to write these stories, even harder to edit them and add in scenes. Then it posed the question of how I had handled my own parents divorce. My coping mechanism had been to ignore what the situation had been at the time, throw a fit, and walk away. I could not do that with this project. I actively sought out help through the Counseling Center and became confident with my past experiences and how they have affected me and still affect me today. Because of this project and my experiences with the Counseling Center, I came to terms with my situation. I became motivated to make this collection. I had to go through my experiences alone, but I did not need to anymore and neither did the children I wrote for. Almost half of all marriages end in divorce in the United States, my therapist told me. So one out of two children have gone through something similar. It may be difficult to understand how someone can feel alone when divorce is a common occurrence in the twentyfirst century, but feeling alone is a common way children express themselves after a divorce. With this collection, I hope to show children that they are not by themselves and that there are other children experiencing the same situations and can find comfort in that knowledge. J. Tillman 15 References Burroway, Janet, Elizabeth StuckeyFrench, and Ned StuckeyFrench. Writing Fiction: A Guide to Narrative Craft . Boston: Longman, 2011. Print. Gardner, John (1992.) Excerpt from The Art of Fiction: Notes on Craft for Young rd Writers . In Janet Burroway, Writing Fiction: A Guide to Narrative Writing, 3 ed. HarperCollins Publishers: New York, 1992, Print. Goldberg, Natalie. Writing Down the Bones: Freeing the Writer Within . Shambhala Publications, Inc.,: Boston, 1986. Print King, Stephen. On Writing: A Memoir of the Craft . Scribner: New York, 2000. Print J. Tillman 16 Appendix A: Product Produced Welcome to Fallen Crest Feet thundered down the hallway and Charlys door slammed open. Merry Christmas! the twins shouted, jumping on her bed and shaking her awake. Santa came, Charly! Robert said as Louie giggled before they both shot out of the room, through the kitchen and to the living room. Charly rubbed her eyes and sat up, looking around her still new room. It was still strange to wake up to purple walls instead of sparkling pink. Charly crawled out from under the covers, made her bed, put on her crooked glasses (which could never stay fixed with two very excited sevenyearold twins) and grabbed a package wrapped in scraps of wrapping paper and newspaper comics before heading out to the living room to join the twins. Mom sat on the couch, Robert and Louie bouncing around like they had to pee. Charly, Mom said. Would you like to do the honors of playing Santa this morning? Well, dont we usually watch a movie and eat breakfast first? Charly asked. Usually, but we dont have a DVD player since we moved. Well, Charly held the package in front of her, Santa presents her first gift. Charly handed the package to Mom. Mom gave her a quizzical look before gently peeling the wrapping off. J. Tillman 17 Rip it! Louie shouted, laughing when Mom tore at the paper and threw it on him. Once the commotion of the paper fight calmed down, a small DVD player sat in Moms lap. She smiled down at the small piece of hardware and held it gently in her hands. Charly, you didnt have to do that, honey. Santa decided that you needed a gift as well. So now we can watch our movies again. Charly beamed and Mom pulled her close. Thank you, she whispered in Charlys ear. Merry Christmas, Charly whispered back, before joining the boys on the ground. Well, since weve got our new DVD player, lets boot it up and pick out a movie for this morning. Mom stood and connected the player to the TV while the kids fought over which movie to watch. Charly wanted How the Grinch Stole Christmas , the live action one because it always made her laugh. Robert had always been a fan of Rudolph the RedNosed Reindeer and Louie was content to continue watching the fire crackle on the TV from the local news station if it meant they got to open presents earlier. Mom said that wouldnt work because it was Christmas Movie Morning, then she threw out the option of Little Women (What does that have to do with Christmas? Louie asked, crossing his arms tightly across his chest). The family finally decided on A Christmas Story , shouting Youll shoot your eye out! at each other while the movie loaded. Just before Mom was going to push play, the doorbell rang. J. Tillman 18 Ill get it, Charly said, standing up and heading towards the door, but the twins barreled past their older sister of three years and flung open the door, Louie shouting, Dad! before running out the front door, Robert close behind. Dad stood outside the door with a few packages at his feet as he picked up Louie. Hey there kiddo, he said. Having a good Christmas morning? Oh yeah. Were about to watch A Christmas Story . Come and watch it with us, Louie said. Oh alright. Guess you roped me into it, Dad said jokingly, setting Louie down and grabbing the packages at his feet. Mom didnt look too thrilled to have Dad in the house, but she smiled and opened the door wider. Merry Christmas, Mom said, receiving a nod from Dad as he knocked snow off his shoes and walked to the living room. The twins sat with Dad on the couch and Mom and Charly pulled in chairs from the kitchen, letting the movie start. Charly looked between Mom and Dad. The last time they had been in this house at the same time hadnt been a good day. The kids had returned from their fall break with Dads sister, Aunt Faye, in Kentucky, but they had pulled up to this new house instead of the one that they lived in. The trip seemed to be one of the last happy moments that the three of them had. *** Mom stood outside a new house with a big smile on her face, while Dad stood further away, arms crossed, and smiling slightly at the car. Aunt Faye parked the car and helped the boys out of their car seats while Charly pulled the bags from the trunk. J. Tillman 19 Hey there, kiddo, Dad said, giving Louie and Robert hugs and waved at Charly as she struggled with the three bags. Mom came over to help her. How was break? Dad asked the twins. It was awesome! We got to go on a bunch of roller coasters. Louie got sick! Robert said. Did not! I just didnt feel good, Louie said, giving Robert a small shove. The twins chatted Dads ear off about all the different places they had gone while Mom and Charly walked inside the unknown house and placed the bags on the floor. Mom? Charly asked. Mom wouldnt meet her eyes. Where are we? Were home, Mom mumbled too softly that Charly had to ask her a second time. Mom was trying to keep her tears in, but Charly saw them and knew something was about to happen. Robert and Louie ran around the house to the sounds of laughter, ignorant and blissful. Dad and Aunt Faye stood off to the side in the living room, talking in whispered voices. Charly tried her best to ignore them and focus on the boys, but it was hard when she knew that this was not the familys house, but Moms. Kids! Come say goodbye to your aunt. Shes heading back home, Dad said. Bye, Aunt Faye! the twins said in unison, each giving her a quick hug before running around the house a second time, flying up the stairs this time to explore the upper level. Thank you, Charly said, giving her aunt a hug that seemed to last a little longer than it should have. Aunt Faye bent down and looked Charly in the eyes. J. Tillman 20 Youre my favorite niece, and I cant believe that you put up with your annoying brothers so well. Aunt Faye got Charly to laugh and stood up. Just remember, you can always come visit me any time you would like. Thank you, Charly said again and watched Aunt Faye walk out the front door, Dad closing it behind her. He then guided Charly into the living before going around to various rooms in the house to catch the boys and have them sit on the floor in the living room with Charly. Mom? Robert asked once everyone had sat down. Where are we? Well, bud, youre in a new home, Dad started to explain before folding his hands together and staring at his feet. Mom and Dad are going to be living in different houses from now on, Mom continued when Dad didnt. Why? Louie asked. Why cant we just stay in one house? I like it there. Mom and Dad are getting a divorce, Dad said, still not looking at anyone, but finally speaking again and breaking the silence that had fallen on them. This made Charly close her eyes and do her best to not cry too much in front of her brothers. What does that mean? Robert asked tentatively, looking over at Charly, his protector, only to see her upset and crying. He crawled over to her and snuggled into her lap, having always been extremely close with her. When Robert would cry as a baby, Charly would pull him into her lap and calm him down. Now Charly was upset and it seemed to her that this was Roberts attempt to calm her down like she always did for him. When Robert was nestled in her lap, Charlys tears came more steadily into the back J. Tillman 21 of Roberts shirt, grateful for some comfort and normalcy, but she still refused to talk, even with Robert silently nagging her to speak anything. Mom, why is Charly crying? Louis asked, confused by his sisters reaction to the news. Well, when Mom and Dad get a divorce, Mom explained, It means that they are no longer going to live together because they no longer love each other. That doesnt mean that we dont love you, but Mom and Dad dont want to live with each other anymore. Is it something we did because we can change? Then we can stay together, Louie said as Robert nodded vigorously. Louie and I can clean our room willingly and we wont fight as much as we normally do, all three of us. This made Mom cry through her smile. Sweetheart, it has nothing to do with you three. This is between Mom and Dad. Will we live here? Louie asked, looking around the small barren house their aunt had dropped them off at only a few minutes earlier. Yes, Mom said hesitantly, looking over at Dad, who had stopped talking again. This is my house now. Youll be living here with me most of the time. Will we ever see Dad? Louie tapped his fathers knee as Robert leaned into Charly more as he tears stopped but the shakes of anger began. J. Tillman 22 Of course, honey. You will see both of us all the time. We will be moving some of your things into this house and some of your things will stay at Dads. The next goal to decide is what goes where and we will leave it up to you three to decide. Sound good? Charly shook while she held onto Robert. Why were her parents doing this to her, to the twins? She knew people at school whose parents were divorced, but they were usually kids who were a bit on the weirder side, or those who bullied other kids. Charly was a normal kid, and she liked it that way. Mom and Dad now made things not normal and that wasnt how things were supposed to be. What was going to happen to her now? What was she supposed to do to be normal? Everyone at school would probably make fun of her and she wouldnt have anyone to turn to except the teachers, and even then, she didnt want to be known as the teachers pet. That is how kids alienate themselves from their friends. She needed a friend who understood what was going on, but she didnt know anyone who was going through this, making her the weirdo and no one would understand or would know anything. Her parents were ruining her life and she was only ten years old. How was she supposed to handle the rest of her life? Come on, lets go. Dad stood up and walked to the front door. Before the rest of them could gather their thoughts or even begin to move towards the front door, Dad sat in his car and drove off to their old house. Mom sighed, helped the kids into their car seats in her car, and drove back to the house that used to belong to the entire family. That night, while everyone else slept, Charly stayed up late writing letters to her teachers, whom she loved at Fall Creek Intermediate, about the situation that was going on with her family and how things were changing for the worse for her. She had actually gotten a J. Tillman 23 few responses from her teachers, especially Miss Martin, who taught English, and Mrs. Kaiser, who taught math, who wanted to help her out with school as well as being friends with her, since she didnt have any. *** Charly smiled, remembering where she had put the letters from her teachers as Ralphie almost shot his eye out with his Red Ryder BB gun on Christmas morning, ruining his glasses. The twins laughed, but no one had really spoken throughout the movie, just mocked the tagline and laugh at everything Ralphie and Randy got themselves into. The movie ended shortly after and Dad bypassed breakfast to hand the twins their gifts and tossing Charly hers, even though Mom was already cooking in the kitchen. Santa decided to stop by my house as well, so these are from Santa, he said. I thought Charly was playing Santa, Robert said, but no one paid attention to him. Louie tore open his box. Thanks Dad! Louie said, holding a brand new portable CD player in his lap while Charly and Robert ripped theirs open. All three of them got the same thing. Thanks Dad, Robert said. Louie gave Dad a hug. Dont thank me, Santa knows what you like, Dad said, hugging the twins back. Now you can take music anywhere with you. Yay! the twins cried in unison, eying the presents under the Christmas tree. But we dont have any CDs, Charly said. Dad didnt seem to hear. Mom came back into the living room and tossed Charly the Santa hat. J. Tillman 24 Charly, would you play Santa this morning? she asked. Charly beamed, tossed the CD player to the side, and crawled towards the tree, followed closely by the twins. Charly moved slowly, just to make the twins upset. Hurry up Charly, or I will steal your hat, Louie said, making a grab for the hat, but Robert tackled him. Dont take the hat. If you do, she wont give us anything else from Santa and it will have to be wrapped under the tree until next Christmas. Dont do it, Robert said, his brows furrowed in concern. I was only joking. Louie pushed Robert off of him and they both sat against the couch Mom had turned on the fireplace from the local news station again. Charly handed out a small number of presents to the twins and herself. The sound of ripping paper filled the room. Wow! Charly, look Robert said, bouncing off the couch and sitting next to Charly, who was in the process of opening a large box that sat between her legs. I got Pokmon Sapphire and Louie got Ruby. We got the newest Pokmon game! Charly noticed a used sticker on the back of the cartridge, but smiled at Roberts excitement. Thats super cool. Robert! Louie shouted from the couch. Charly and Robert looked over to see Louie holding up a cord with a huge grin on his face. A connector cable! Robert shouted, running back to Louie and they both held the cord carefully. We can trade and battle now! J. Tillman 25 Both boys stared at each other in shock, mouths gaping open before hugging Mom. Thank you, they chimed in unison. Why are you thanking me? They came from Santa, Mom said as she hugged the twins back. You talk to him, so you can tell him thank you for us, Louie said. For both these and the CD players, Robert added. Of course I will. Now lets see what Charly got from Santa. What did you get Charly? Louie asked as Robert came and sat next to her. I dont know yet, I havent opened it yet, Charly said. Can I help? Robert asked, reaching out for the red and white wrapped package still between Charlys legs. Mom cleared her throat and Robert froze, Louie giggling as he returned to the couch to sit with Dad. Did Charly say you could help? Mom asked Robert. No, Robert mumbled and bowed his head. Okay. This is Charlys present from Santa, so she should be allowed to open it. Yes, Mom. Robert sulked over to corner by the TV where the pile of blankets sat folded where he flopped face first into it, hiding his hiccups of embarrassment. Charly rolled her eyes at her brothers dramatic overreaction and ripped off the wrapping paper to throw it at him. Get up Silly Butt and quit pouting. Its Christmas, she said. J. Tillman 26 Robert smiled and threw the paper back, coming to sit by Charlys side again. Underneath the wrapping paper was a large shipping box. What do you think is inside? Louie asked from the couch. I dont know, but Santa is full of surprises, Mom said with a smile on her face. Once Charly got through the tape, she found five books inside, grabbing the smallest one to find a boy flying across the cover on a broomstick. Residue of a sale sticker still stuck in the upper righthand corner. Its a really popular series out right now and Santa thought that you would enjoy it to pass the time. Charly didnt say anything, but got up and hugged Mom. Thank you, she whispered. Your welcome sweetie, Mom said. Charly had given up on Santa a few years ago. Mom and Dad didnt know, but Charly had found her Christmas gift from Santa tucked under the back seat of the truck and knew that this jolly old man was just a fantasy, even though she wanted to believe in him wholeheartedly minus the whole watching her year round part. That was just plain creepy. She kept up the belief for the twins. She loved seeing the smiles on her brothers faces, especially after the rough year they had all had, when all of them were scared of the world. Besides, Mom was the best when it came to presents and surprises. Even when they had just moved into this house, Mom pulled out all the stops. *** J. Tillman 27 Welcome home! Mom said, opening the door to their new house. Sure, Charly and the twins had been moving things from Dads to here for the past two months, but everything had been painted, unpacked, and put away. Wow! Robert said as Louies mouth fell open. The house had a lime green front room that led to a burgundy red dining room, the same as in Dads house now, before he decided to paint it white again, wiping away Moms design from the house. To Charly, the house felt cozier than it did at the Dads house, even when they were all a family in the same house. Just the four of them felt better. She smiled and hugged Mom. Charly? Mom asked, wrapping her arms around her eldest child, who had taken the divorce hard. Are you okay? Im happy, Charly mumbled into her mothers shoulder, squeezing Mom tighter. Im happy that youre happy. Mom let go of Charly and wiped a stray tear away. They both giggled before Mom pulled the boys back over. Now, I know that Christmas isnt until next week, but Ive been talking with Santa and we both decided that you three have been extra good this year and each of you have a small gift. Really? Robert asked, his eyes glowing as his voice reached a dolphin level of hearing. Really, Mom said. But I told him no. J. Tillman 28 No! Mom why? Louie interrupted and then burst into tears as Robert threw himself as Moms feet, repeating what Louie had said. Charly and Mom laughed, trying to calm screaming twin boys. You didnt let me finish, Mom protested, wiping tears from Louies face. Robert had abandoned Mom and now cowered behind Charly, his protector. As I was saying, Santa wanted me to just give you gifts because you are so good. But I know all three of you are super smart, so I told Santa, No. Im going to hide them around the house and have my superduper smart kids find their gifts around the new house. Of course Santa agreed, saying he had never seen smarter kids. So we still get a present early? Robert asked, peeking out from behind Charly, still clinging to her arm. Yes, of course, Mom laughed. Santa wouldnt tell me that and then I wouldnt let you go find your gifts around the house. Plus, you get to explore the house and find your rooms. The twins glanced at each other, then up at Charly, who looked back at them, before the three of them took off running through the house. No fighting! Mom shouted as door slammings shuddered the house. Robert and Louie shouted at each other as they shut doors in the others face. Charly did her best to stay out of the way, but Louie slammed a door in her face, laughing deviously. Three seconds later, the door opened and Louie came barreling out and down the hall. J. Tillman 29 Eww, its Charlys room. Its all purple, he said before he slammed the bathroom door shut, shouting that he had to pee. Louie! Robert opened the closet door he had been hiding behind, holding his nose. You dont have to tell everyone. The bathroom door opened and Louie grinned. All done. Hands, Mister, Charly said, snapping her fingers at him to get his attention. I did, Louie said. Do I need to smell them or should I just tell Mom? Charly laughed when Louie hid his hands behind his back. No. Go wash your hands then. Robert laughed as Louie stomped back into the bathroom. Get out of the closet, Robert. Your present isnt in there. Charly saw a blur dash out of the closet from the corner of her eye as she entered the room Louie had shouted was hers. Lavender walls and a silky purple bedcover greeted her inside the door. Clearly her room. It seemed to be the same size as the one at Dads, but this one was on the first floor and had no windows. A mini Christmas tree twinkled on her long dresser that had a plate of homemade oatmeal raisin cookies on it, her favorite cookie that Mom made especially for her. Charly grabbed a cookie before exploring the room further. Under the bed was a storage bin of her summer clothes next to a small new suitcase, most likely for travelling between the houses, Charly decided she hadnt left any clothes at Dads because she didnt have that many to start with. Next to the longest J. Tillman 30 wall by her bed stood the desk with its own lamp and a fiveshelf bookshelf, sparsely filled with books. She hadnt been a big reader, but it did keep her preoccupied for a while. The closet had coats, jackets, and dresses hung inside other boxes held shoes, toys, and other random things Charly liked to collect. Everything was put away and organized, just the way she liked it. Charly? Mom asked, opening the door slightly to peek her head in. How do you like your room? I love it. Thank you. Charly said, smiling at Mom. Charly! Robert squeezed past Mom, holding something in his hand, with Louie shortly behind him with a small blue bowl in his hands. Look, Charly. I got homemade Rice Krispy treats. Louie got JellO filled with whipped cream, just like Gramma makes. Louie shoveled a spoonful of JellO into his mouth, smacking his lips loudly as he pulled the spoon out and put it back into the bowl. All four of them laughed as a normal family. Now here they sat, separated again by the presence of a new person, Dad. Oh, I almost forgot. Dad pulled out an envelope from his shirt pocket. Aunt Faye sent me pictures of your trip down there for fall break. Dad handed the envelope to Charly, opening it to see the front picture of her and the twins standing in front of the newly built white entrance pathway of Churchill Downs. All of them wore jackets because of the intense wind that day. *** J. Tillman 31 Charly, Robert, Louie. Are you guys packed and ready to go? Aunt Faye is here, Mom called from down stairs. Charly was packing a few more things into her bag that she most likely wouldnt need but it wasnt bad to be over prepared when she heard Robert and Louie bound down the stairs, their energy filling the whole house with laughter. Charly? Coming, Mom! Charly shouted, heaving her bag onto her shoulder and shutting the bedroom door behind her. Look out below! Charly said as she tossed her bag down the stairs, bowling for twins. Robert jumped out of the way, but Louie got knocked down at Moms feet. Score! Charly skipped down the stairs and landed solidly in front of Mom. Charlotte, Mom said, placing her hands on her hips. What have I told you about bowling for the twins? She bent down and helped Louie to his feet. I know Im not supposed to, but its fun. No its not. Louie threw his bag at Charly, who side stepped and watched it hit Robert in the chest. Ow. Come on! Robert almost launched himself at Louie but Mom stepped in and tossed the bags out onto the front porch. Thats enough. Aunt Faye is in her car, ready to go. She is super excited for all of you to come visit her over fall break. I want you to behave though. Dont come back werewolves or anything. J. Tillman 32 Promise! Louie and Robert said and headed outside where Dad was transferring car seats into the back of his sisters car. Charly? Mom asked her when Charly didnt say anything. Promise? No guarantees, but I will try my best. Thats my girl. Mom started outside, but Charly still stood in the doorway, looking at the twins and remembering that her parents mail had been coming for them separately instead of together like it usually did. Is something going on between you and Dad? she asked. A pressure was released from her chest because she had wanted to ask Mom that for a while. Sweetheart, dont worry about Dad and me. We are big kids and can handle ourselves, okay? Mom said. Charly nodded her head and smiled, heading outside to hop in Aunt Fayes car. She knew something was wrong, but she didnt want to upset Mom with all of her questions. Mom helped Aunt Faye load up the bags in the trunk and made sure the kids had gone to the bathroom and had decent snacks and sufficiently charged Gameboys for the twohour drive south to Louisville. Then the four of them headed off, waving out the window to their parents as they headed off for this incredible adventure. Robert and Louie seemed impossible to control that day. It was right in the middle of break and this days activity had been picked by Charly horses. While they thought that it wasnt that entertaining at first, it soon became a competition between the kids to bet on the horses that would win. J. Tillman 33 Now, you cant place the money yourself, but I will give each of you twenty dollars to bet with on the horses today. Whether you bet it all and win some or dont win anything, today is supposed to be fun, Aunt Faye said, holding three twenty dollar bills up and putting them back in her purse. Now, theres only one or two races an hour, with a total of ten races today. Each race has about twelve horses racing and we can see them and decide who we think the winner will be. Then I will head to the betting station and put your money on the horse. After that, its a return to our seats to watch the race. Let me know if you have to go to the bathroom or if youre hungry. And please, she stressed to the twins, stay close to me and dont leave your sisters side. We have gone to the amusement park and the aquarium the past two days, this is what she wanted to do today, so be on you best behavior. Yes, Aunt Faye, Robert said, taking Charlys hand. I will, Louie saluted to her. Alright, lets head inside. The whole day was spent in two different places: the newly built suites that sat above the race course, and the viewing arena where the horses got ready and everyone could place their bets on which horse would win. The twins bet on which one had the coolest name, Aunt Faye bet on the prettiest horse, but Charly got a tip from one of the employees on how to read the stat guide they were given when they first arrived. Once she learned that, Charly made knowledgeable bets and actually made a few dollars on each bet, but nothing extremely crazy. J. Tillman 34 Why does Charly keep winning? Louie whined after the fourth race, a hot dog covered in nacho cheese halfway to his mouth. Because she knows which horse is gonna win. She can speak to them from the balcony we stand on, Robert said, laughing. You never know. Us Stephens girls are really good at reading minds. Aunt Faye winked at Charly, making Charly smile. By the end of the night, Charly had made her money back, but the twins and Aunt Faye had lost their twenty dollars. To celebrate the win that Charly made, Aunt Faye took the kids out for some deep dish pizza near the racing track, one of her favorite spots. By the end of dinner, Louie was covered in marinara sauce, Robert was shoving down bread sticks, and Charly laughed at both of the boys. Too soon it was time for the three of them to head back home and go back to school. Aunt Faye sat weirdly quiet the entire ride and that put Charly on edge. The boys entertained themselves in the back seat and didnt notice that anything could be wrong with their lives, but Charly knew something was about to happen, and she didnt like the feeling of it. The feeling was made worse when they drove to a different house instead of the one they had left called home. *** Charly quickly shut the envelope, remembering that the trip was fun, but she now knew what happened next and didnt want to remember the pain she had started to let go of. Thanks. Ill write her a letter to say thanks. J. Tillman 35 There ya go, kiddo. Dad smiled at her and she sat down next to her box. Robert and Louie ran off to their rooms upstairs, shouting about Pokmon before the door slammed shut. Im gonna head to my room too, okay? Charly asked. I want to start reading these. She motioned to the box in her arms. Dont forget your CD player, Dad said. Ive got it in here. The CD player still sat on the floor. Okay. Breakfast will be ready in a little while, Mom said. Okay. Charly set the box down on the bed and was about to close the door when she heard Mom and Dad talking. Im surprised you didnt bring her along and just introduce her to the whole family at once. Would have made for a very Merry Christmas, Mom said. I dont know who youre talking about, Dad said. Oh horse shit, Ed. Dont play dumb with me. You know who Im talking about. She showed up at the goddamn park when we were still married. Its not like you couldnt tell you both were more than just friends. *** All of them used to go to the park all the time. Only at the end of summer break did Charly notice anything different. Higher Mommy, higher! Robert shouted on the swings, kicking his legs wildly. Louie decided to climb on the outside of the covered slide when he had been strictly told J. Tillman 36 not to, and Charly hung from the monkey bars by her legs, hitting her chest like a Gorilla to make the twins laugh. She turned to find Dad, but he no longer stood under the slide, watching to make sure Louie wasnt going to fall. Charly quickly flipped out of the monkey bars and went to stand under Louie, hoping he wouldnt fall and crush her skinny, boney frame. Once underneath the slide, Charly heard Dads voice. On the other side of the bridge connected to the slide Louie was climbing, Dad was on his phone, and the other person was making him turn pink and giggle like Mom used to when Dad would tickle her neck with his stubbly beard before he shaved it off. He didnt do that anymore. Yeah, come on over. Im by the bridge on the playground facing the soccer field. Yeah Ill look for you. See you soon. Love you too. Bye. Dad snapped his cell phone shut and noticed Charly looking at him. Whats up, kiddo? he asked. Who were you talking to on the phone? Charly asked. An old friend is in town and she wanted to see if she could visit, Dad replied. So, shes coming here? Yeah. Actually, I think she is coming this way. Dad pointed to the red minivan that pulled up in front of the welcome center a little way from them. Now, shes a little shy, so Im gonna ask you to stay here with your mom and brothers while she and I catch up, okay? Yes, Dad. Charly looked down at her feet and kicked at a few pieces of mulch as Dad walked over to the woman and gave her a hug and a kiss. Charly stood dumb J. Tillman 37 founded at the pair of them Dad didnt kiss anyone besides Mom. The pair sat down near the welcome center and talked. The other woman talked excitedly with her hands while Dad laughed and put his arm around her shoulders, something else he only did with Mom. Louies sneakers squeaked on the outside of the slide he was currently climbing. Charly stepped back to see he had lost a shoe. Come on Louie, get down, Charly said. No! Louie pouted, pulling himself up a little further. Mom said I could be up here if Dad watched, right, Dad? Charly paused before she spoke. Dads not over here. Hes talking to some lady by the main building. What? Louie tried to lift himself up to see where Dad went, but he slid down another foot, his butt in Charlys face. She scoffed and pulled him down onto the inside end of the slide while she went to find the missing shoe. Charly came back shortly, picking mulch out of the shoe and handing it to Louie to put on. I dont know how to tie my shoes. Louie complained. Youre almost in second grade. Yes you do. Now put on your shoes. Louie pouted but listened, slipping on his shoe before standing up and walking over to the swings where Mom swung next to Robert. Charly, swing with us! Robert shouted. Louie ran forward ahead of Charly and snagged the swing next to his twin. Charly shrugged and sat next to Mom, but didnt swing much. Her mind was preoccupied by Dad and the other woman. J. Tillman 38 Charly, honey, whats wrong? Mom asked, coming to a stop. Dad is sitting with another woman by the main building, Charly said reluctantly. Who is she? Mom asked, standing up to get a view of Dad and the other woman from across the playground. He says shes an old friend from college who happened to be in town. But Mom, Charly confessed, looking down at her feet. He said that he loved her. Mom froze, staring at the pair of them. Her face dropped and the smile disappeared from her normally cheery face. Oh, she said, hanging her head and sitting back down in the swing, staring at her feet. Charly knew then that something was wrong, and she was terrified that she had said the wrong thing, but kept that to herself she didnt need to worry her mother anymore than she already had. *** I wasnt planning on bringing Tasha to your house, Amanda, Dad said this Christmas morning. Wouldnt put it past you, Mom mumbled. Besides, shes spending Christmas with her own family. Oh, so youre ruining two families instead of one. Glad Im not the only one. Hold on a sec for fucks sake, Dad raised his hand and pointed at Mom, who wielded a wooden spoon sizzling with sausage grease. Youre the one who wanted the divorce. Dont make me out to be the bad guy. J. Tillman 39 Oh, so am I the bad guy? Mom scoffed. Youre the one who was fucking another younger, skinnier woman behind my back. Marriage is a twoway street, Ed. You cant blame this all on me! But I am, because I tried my damndest to keep us together, but that doesnt matter. Im just not good enough for you and neither are your children. Dont bring them into this. Well you should have thought about that before agreeing on the divorce, because no matter how you spin it, the kids get the worst of it. They now dont have a real home. The sausage sizzled in the frying pan, filling the house with its irresistible scent. Charly could hear commotion in Louies room upstairs where the twins had been for the past ten minutes or so. I let you in my house, share my food with you, and I let you be Santa Claus along with me. These things are confusing to the kids and to me. It seems like you care about all of us again, not just the kids, Mom said. Eggs screamed to life next to the sausage. I didnt know you were gonna be Santa. Its always been me to dress up and go down stairs dressed up as him and deliver the gifts under the tree. What did you do about that? Dad argued back. I know! You didnt do anything because the suit is in my attic, getting eaten by raccoons. Charly heard the stairs creak above her the twins were planning a sneak attack. Well the suit being eaten by raccoons is your own damn fault. All Im saying is that for next year, Im gonna be Santa. I dont want to confuse the kids. J. Tillman 40 You just dont want me winning because my Santa brings better gifts than your handmedown gutter Santa. Fuck off, Ed. Why dont you go play Santa somewhere else? You arent wanted here. But Im Santa. Santa isnt real Mom stopped short as the stairs creaked more. Mom? Robert asked. Is Santa not real? Louie finished. Mom and Dad looked at each other before Dad smirked. Looks like another thing you ruined for the kids, Dad said. Mom raised the spatula at him, but quickly put it down before pointing at the door, her glare turning dark. Get out of my house, Mom growled through gritted teeth. Dads face went red and he glared back before he stormed towards the front door, knocking Robert over on his way to his car, Louie running after Dad. Charly walked down the hallway and helped Robert to his feet as Louie came back inside, tears on his cheeks. Honey, whats wrong? Mom walked over to Louie, wiping away his tears. Dad wore the Santa suit, didnt he? J. Tillman 41 Water Hazard The doorbell sounded outside my room, startling me back into reality. I peeked out the window. Great, Dads truck sat in the driveway. I forgot it was Wednesday. I bookmarked my place in the book, refusing to dogear anything, and headed to the front room where Dad stood waiting. Louie came running down the stairs and jumped into Dads arms, Robert standing back and holding my hand. Dad halfsmiled at the group before setting Louie down and heading out the door, each of us grabbing our overnight bag and following him. Be safe guys, okay? Mom called after us as we piled into the truck. Louie called shotgun, so Robert and I got the half seats with the bags. Were going puttputting at Ben N Aris! Dad said as he pulled out of the driveway. The boys cheered. I sat in silence. Putt putting could be fun, as long as the boys didnt lose their putters in the water hazards again and make me go swimming accidentally while trying to fish the poles out with the net. It would be a fun night. The quick fiveminute ride was filled with the boys chattering about how awesome they were at puttputting and how they were going to cream Dad with their master skills. They also promised me that they wouldnt make me go swimming again. As we pulled into the parking lot, I noticed an extremely tall, beanpole thin woman looking at their car with a high school boy on his phone next to her and a smaller twin version of the beanpole woman running around and collecting rocks that surrounded the puttputt course. I eyed them suspiciously, I knew that woman from somewhere, but J. Tillman 42 stopped wondering when Robert couldnt wait for Louie to get out of the car any more, so he climbed into the seat with him and opened the door before the truck had come to a complete stop. Robert, calm down there, Dad said, putting the truck in park. Louie and Robert scrambled out of the truck, not remembering that I was still in the back seat. I reached around the side of the passenger seat and pulled the lever to send the chair forward so I didnt have to climb over and around the seat to get out of the door. By the time I shut the door, the woman had come up to Dad and gave him a hug and a kiss on the cheek. I took one look at this new pair and pulled on the truck handle wanting to hide inside even though the truck smelled of farts thanks to the twins, but Dad locked it, so I couldnt escape. Dad pulled me closer by my elbow to introduce me to the others. This is my eldest and only daughter, Charly, Dad said. Charly, this is a good friend of mine, Tasha. Its nice to finally meet you, Charly, Tasha said, leaning forward and extending her hand to me. I made no move to return the handshake. Tashas smile faltered a little bit, but soon looked over at the twins. And who are these handsome gentlemen here? she asked. Im Louie, and this is my twin brother Robert. Louie stuck his hand out to shake Tashas, Robert a bit more tentative. Rob and Louie, fine names indeed. Its Robert, Robert said to his feet. Tasha ignored him. J. Tillman 43 Well, its nice to meet all of you. These are my children. This is Shaunda. Tasha pointed to the look alike. Hearing her name, Shaunda dropped the rocks she had been playing with and came to stand next to her mother, a bright smile on her face. Hi! Shaunda practically shouted. Everyone laughed except me. I stared at the girl with a curious look on my face that made Shaunda break eye contact and shuffle her feet. And this is my eldest, Ian. Tasha yanked the teenage boy closer. He didnt look up from his phone, fingers flying as they sent text messages, grunting his hello. Louie looked at Ian with pure amazement in his eyes. We stood awkwardly in the parking lot, Ian finally noticing that he was being stared down by Louie, who then looked down at his feet before we were pushed toward the entrance. The arcade itself wasnt like one of the old arcades that everyone imagines. Those ones have fighting games like Street Fighter or Mortal Kombat , racing games, lucky chance games (my favorite being Power Tower ), skee ball, and shooting games. Ben N Aries only had old broken lucky chance games. No one knew why this family owned place was still open, but they had a duck pin bowling alley down the middle of the rectangular building, five party rooms lining the wall behind the bowling alley, a concert hall for local bands that was a glorified larger party room, and putput outside with two different courses. We had to go inside to pay for the putt putt, get our putters, golf balls, and score card. Then it was back outside to start the course. It was early enough in the afternoon that it wasnt crowded, so this hodgepodge of people I was a part of had the J. Tillman 44 entire course to ourselves, which seemed like a good ideaShaunda was all over the place and Ian couldnt keep up with the group because he constantly stared at his phone. Ian! Tasha yelled at one point. He had sat down on a bench with his putter between his legs, texting and ignoring the group. Ian! Tasha called again, but gave up and let him sit. I thought that might work with Dad, that is, if only I had brought my book. Dad, can I sit over by Ian? I asked. Sure. Go make friends. I was surprised Dad has said yes that I looked at him dumbfounded before regaining my composure and sitting on the bench near Ian, watching the clouds overhead since Dad said I was too young to have a cell phone. We sat in a comfortable silence, not the awkward silences I sometimes got from Dad when he doesnt know what to say. I didnt catch your name earlier, Ian said, glancing at me. Charly, I said. Short for Charlotte. Im Ian. Ian stuck out his hand and I shook it. He shoved his phone into his pocket and nodded his head towards the rest of the gang. They seem to be getting along well. Yeah, I said, looking at Louie and Shaunda laughing at each other. Robert hung back wanting to be part of the fun, but getting pushed aside. Louie and Shaunda really like each other. Yeah. J. Tillman 45 We watched in silence while the kids play putt putt. Robert looked over at us and waved. We both waved back. I turned to look at Ian, but I heard shouting from Louie. I looked back to see Louie shove Robert a bit too hard and Robert fell over the rope barrier of the bridge and into the water hazard. Panic set in and everything slowed down. Robert fell, letting go of his putter before splashing into the water, his putter hitting his stomach before he disappeared under water. I stood but didnt movehe would be fine. But he cant swim, idiot! the voice in my head screamed. At that, I kicked off my flipflops and bolted for the water Robert was nowhere near the surface. Charly! someone shouted after me before I jumped in. Robert had always been afraid of water when he discovered he couldnt really float and was a natural sinker. As I swam further down, the pressure built. I grabbed Roberts arm and pulled him around my neck and also managed to grab the putter, which I used to push off the floor towards the surface. When Robert was above water, he gasped and coughed up water. I swam us to the edge where Tasha and Dad pulled Robert off my back and doted over him, leaving me in the water. I put the putter on the side and got ready to hop out when a hand appeared in front of me. Ian stood with his hand out for me to take. I took his hand and got out of the water, bending over to catch my breath. Thanks, I mumbled, looking over at Robert being swallowed by the other five. Dad looked around frantically until his eyes landed on me. J. Tillman 46 Charly, go get management, he said, turning back to Robert. I sighed and began to walk towards the door I was the one who could comfort, but Dad always thought he knew best. I made it halfway to the door when three employees ran past me, towels and arcade shirts in hand. I ran back and found Robert buried in shirts, Louie and Shaunda crowded close while Dad argued with the eldest employee who I recognized as the arcade owner from all the times the twins had a birthday party at the arcade. All Im asking is why the fuck the water hazard is so deep? Dad asked, his face red and arms crossed tightly over his puffed up chest. Sir, it was like that when I purchased the area, the owner said. In hindsight I should have filled it. I will take full responsibility for this. Youd better, otherwise youll be hearing from my lawyer, Dad threatened. I will make the hazard under four feet deep, make the bridge sturdier, pay for any distress this caused your family, and give you and your family lifetime passes for putt putt and bowling, the owner pleaded with Dad. Ill even throw in free pizza from the arcade and deliver it directly to your house when it finishes cooking so your kids dont have to sit here in their wet clothes. Alright, thanks, man. Dad shook hands with the owner, who let out a sigh of relief at Dads agreement. What kind of pizzas would you like? Two large cheese and one large pepperoni, that should feed us all. J. Tillman 47 Get a small sausage and green pepper for Robert, I chimed in, wanting to surprise Robert with his favorite pizza. The owner looked at me, but Dad waved me off. Go check on Robert, Dad said before following the owner back inside. I sighed and hung my shoulders hopefully he would do this for Robert. A shirt draped over my shoulders. Ian had snagged one that the employees had brought out for Robert. I pulled it tighter around me. Thank you, I said. You okay? Ian asked. I nodded. Charly, Robert said. He looked at me and held out his hand. I walked over to him and helped him to his feet before he wrapped his arms around me tightly and buried his face in my still wet shirt. We stood like that for a few moments before I started to dry him off with one of the shirts he was buried under. I think we should go, Tasha finally said, walking toward the parking lot with Shaunda in tow after Dad had returned from inside. Okay. Follow me back to the house. Pizza will be delivered in twenty minutes or so, Dad said. Tasha nodded and motioned for Ian to follow her. Ian gave one last look to me, standing on hot concrete, barefoot, soaking wet, and holding my youngest brother, before following his mother back to the van. We have to go, Robert, I said, drying off his hair I want to go home, he mumbled. Were heading to Dads. J. Tillman 48 No, Moms. I sat in a moment of silence. I want to go there too, but its Dads night. But why? Because they said so. Robert let out a shaky breath and looked at me. Come on. I smiled down at him I told Dad to get sausage and green pepper pizza for you. Okay? Robert nodded his head and gratefully took my hand to help stand up, then we trudged off to the truck, both cramming into the back half seats. The drive wasnt more than ten minutes, but uncomfortable in wet clothes. The radio chimed 80s songs in the background. Back at the house wasnt much better. Robert and I changed into pajamas. Ian took most of the long couch, Shaunda had the bean bag chair and Dad and Tasha were sitting in the love seat, with Louie on the floor. Robert and I sat at the table and played war until the pizza came. The Fellowship of the Ring played in the background and no one paid attention to it, yet no one talked, opting for the uncomfortable silence that fell between them. The doorbell rang and Shaunda jumped up to answer the door. Pizzas here! she shouted, throwing open the door. Dad and Tasha followed, coming back with a small stack of pizzas. They placed them in the kitchen, where everyone grabbed a paper plate and pulled pizza in every direction. Did you order sausage and green pepper like I told you to? I asked. Thats disgusting, Shaunda said, piling her plate high with cheese pizza and walking away. J. Tillman 49 No, I didnt. I didnt know that there were any special requests. I got two cheese and one pepperoni, Dad said, grabbing a few pepperoni slices and walking back to sit on the couch. Tasha took a single slice of cheese and Ian took a few of both. Louie took the rest of the pepperoni, leaving 4 slices for both Robert and me to share. Robert looked like he could cry. I took his plate and set it on the counter before pulling him into a tight hug. You promised, he mumbled. I know, but he didnt listen, I whispered into his hair, giving him a big squeeze. I dont want plain cheese and pepperoni makes my stomach hurt. Ill make you something else then, how bout that? I let go of my brother and opened the fridge, only finding a couple bottles of Coors Lite, a limp head of lettuce, and a moldy cucumber. I threw the cucumber and lettuce out and opened the freezer. Only empty ice cube trays. I shut both doors and opened the pantry door, scanning the lines of crackers, chips, and microwave mac n cheese. Robert looked inside as well, pulling down a package of strawberry Pop Tarts and a cup of ramen noodles. You want this? I asked, receiving a nod from Robert. I filled the tea kettle with water and let it heat up while Robert went back to the table and opened his package of Pop Tarts, scattering crumbs everywhere. I put two pieces of pizza on my plate and set it down next to Robert, standing close to the kettle as it warmed up. I opened the cup of noodles as the kettle started to hiss. Charly, what are you making? Dad asked over his shoulder. Cup of noodles, I responded. Why arent you eating what we got? J. Tillman 50 The noodles are for Robert. Robert, you like pizza. Why are you getting noodles? I dont like cheese pizza. Robert spoke with his mouth full to the table Grab some pepperoni, Dad insisted. Roberts eyes welled with tears. Robert, whats the matter? Pepperoni makes his stomach hurt, I said, bringing over the cup of noodles and a fork to Robert. Since when? Since forever. Thats why I asked about the sausage and green pepper. Thats the pizza he likes. Im sorry, Robert. I didnt know. Ill order you your own pizza next time, okay? Robert nodded and all eyes returned to the TV, actually watching the movie this time. I patted Robert on the head and sat to eat my two pieces of pizza. I wanted all four, but knew that as soon as I sat down, someone would snag them and they would be upset with me for stealing the last of the pizza. Sure enough, Louie and Shaunda entered the kitchen at the same time, each taking a piece and sitting back on the bean bag chair together. They were becoming good friends. Ian fell asleep on the couch, a slice half out of his mouth. Ian! Tasha shouted, startling him awake. He looked at his mother, wiped his mouth and finished eating his pizza before going back to texting. The night passed in silence. I cleaned up the kitchen because Dad didnt really know how hence the paper plates. I flattened the empty pizza boxes, shoved them in the J. Tillman 51 trash can, washed Roberts fork and put it away, then went into the living room and took the empty plates and threw them away as well. I wetted a paper towel and wiped up the crumbs from Roberts Pop Tarts and threw that out before returning to my card game with Robert. The Two Towers followed The Fellowship of the Ring and by the end of that movie, most everyone was asleep on the couch or floor except for me. Robert had moved to the floor once he got bored of playing cards with me. It was time for bed. I helped Robert off of the floor and walked him upstairs, kicking Louie and Dad awake as well. Dad looked at his watch and nudged Tasha awake. Its time for bed. Looks like we fell asleep during the last movie, he said. Thats okay. We can watch the last one tomorrow. Tasha smiled and stretched, nudging Shaunda awake. We need to figure out sleeping arrangements. Louie and Robert have a bunk bed and Charly has a day bed with another mattress underneath the one she uses. So Shaunda can sleep in Charlys room. Im assuming Ian is fine on the couch. He just needs a blanket. At the sound of the sleeping arrangements, Shaunda and Louie looked at each other, then gave puppy dog eyes to their parents. I wanna sleep in the bunk bed, Shaunda whined. She can take Roberts bed and Robert can have Charlys spare, Louie piped in, not asking his brother if it was okay. J. Tillman 52 Well, I dont think that would be appropriate, Dad started. He looked at Robert, but saw that he was clinging to my shirt, giving him his own puppy dog eyes. Boys share a room and girls share a room. Thats the rules here. Im not climbing the ladder to get in my bunk bed, Robert said. Its fine, he can stay in my room. I dont mind, I said, putting my arms around Robert. Please, Dad? Louie asked. Please, Mom? Shaunda begged on her knees. Tasha and Dad looked at each other for a quick second before Dad sighed. Alright, fine. Shaunda can have the top bunk and Robert can get the spare bed in Charlys room. Yes! Shaunda shouted, following Louie down the hall and up the stairs at full speed. Ian looked up once. Could I get a blanket? Ian asked. Charly? Dad asked, looking at me over his shoulder. Ill go get one from upstairs. Ill be right back. Thank you, Dad and Ian said at the same time. Robert and I walked up the stairs and Robert grabbed his bag from his room, walking silently over to my room. I opened the hallway closet and pulled out a couple of Christmas throw blankets and headed back downstairs. When I rounded the corner of the hallway, I stepped back as I saw Dad and Tasha kissing. I looked horrified, watching this intimate moment between the two, remembering that Tasha was the woman from the J. Tillman 53 park, the one Dad said he loved when he was still married to Mom. My heart broke and I did my best to hold back tears. Somewhere in my mind, I thought maybe Mom and Dad could get back together, but that thought disappeared with this kiss. I backtracked through the family room and the kitchen to the living room to hand Ian his blankets. Thank you, Ian said. I nodded. Are you alright? You didnt get hurt at the puttputt course, did you? Im fine, thanks for asking. I cleared my throat. If you need anything else, everyone is sleeping upstairs. If you feel uncomfortable down here, theres a futon on the loft you can sleep on. Ill be fine down here, Ian said. Okay, I said and turned around and trying to keep my calm checking the hallway again to see if Tasha and Dad were still there, but they had disappeared upstairs. I walked up, hearing giggles come from the twins room. I opened the door and saw Shaunda on the top bunk leaning her head over and making faces at Louie, who was giggling uncontrollably. Hey, Charly! he finally laughed out and Shaunda whipped her head around to look at Charly. Brush your teeth, I said. I dont have a toothbrush, Shaunda said as Louie groaned, getting out of bed. Use your finger then. Thats gross, Shaunda gagged, plugging her nose. J. Tillman 54 Whatever. I walked to my room and told Robert the same thing. All three young kids crammed themselves into the kids bathroom, so I knocked on Dads door to see if I could use his bathroom, but the door was locked and all I heard was a few grunts before shushed giggling. I knocked again and received stilled silence. Giving up, I waited in the hallway for the kids to be done when I noticed Ian make his way upstairs and lie down on the futon, still in its couch position. I rolled my eyes and nudged Ian, getting him to stand up while I put the bed down. He nodded his head and laid down, watching me as I stood in the hallway. Shaunda ran out of the bathroom with Louie right behind her. I followed them into the room and waited for them to get into bed before I turned the light off and pulling the giant Pikachu pillow stopper in the hallway so the door didnt shut all the way. I dont need that since Robert isnt here, Louie said. Yeah, no one in here is a baby and scared of the dark, Shaunda said and laughed. Watch your tone, I said to Shaunda. She rolled her eyes as I kicked Pikachu into the room and shut the door. Robert finished up in the bathroom shortly afterwards and silently headed to my room, looking sad. I entered the bathroom to brush my teeth, followed in by Ian. When I finished brushing and spit, Ian finally spoke. You really take care of your brothers. Theyre family, I said. That may be, but I would let have Shaunda drown a little bit. She might grow up a bit. Shes fucking annoying. J. Tillman 55 I blushed when Ian cursed I never thought I could cuss because I was pretty sure I would get my butt whipped for saying them. How can you say that about your sister? Halfsister, he corrected me. You have the same Mom? I asked before I could stop myself. No, Dad. So, Tasha isnt your mom? No, but she raised me. Shes a total drama queen. Forced me to come down here this weekend, even though I permanently live with Dad. But Im glad I did. Ian smiled at me. I laughed I wasnt the only one who didnt like Tasha. Well its a good thing you did, otherwise all hell would have broken loose, I said. Ian nudged my shoulder and chuckled. Look at little sis saying big words now. Ha. Ha, I said back, walking out of the bathroom with Ian behind me. Good night, Charly, he said. Good night, Ian, I said back before entering my room and shutting the door. I turned on the butterfly night light for Robert and opened a window after I had pulled out the spare bed and set it up, finding an extra pillow for Robert in the closet. I turned the overhead light off and crawled into bed, curling up around my few stuffed animals. Charly? Robert asked after a few minutes. Yes? I rolled over to face him. His cheeks shined in the faint light. I saw Dad kiss Tasha earlier. J. Tillman 56 Me too. Do think hes going to marry her? Dad wont leave, I said, doubting my own words. Tasha scares me. I dont want her to take Dad away. Robert hesitated for a moment. Why did Louie leave me? Im also scared youll leave me like Louie did today, Robert said after a moment. Louie didnt leave you. He just made a friend and you can be friends with Shaunda too. I tried to stay positive. Shes annoying, Robert said. We both giggled until Roberts laughs turned into silent sobs, making him shake. Come here. I pulled him toward me and wrapped my arms around him, letting him cry into my shoulder. Everything is going to be all right, okay? Ill never leave you, I promise. J. Tillman 57 Scars Charly slams the door shut behind her, locking it before pacing her room, clenching and her fists repeatedly. They couldnt be doing this. They wouldnt be doing this, not to her, not to the twins. They are a family without her . But not like that mattered. Her father isnt going to listen to anything she has to say. After all, who would listen to a moody twelveyearold anyways? No one. She knows that alreadyfar too often people ignore her because of her age. Not anymore. Charly isnt going to take it. In a fit of anger, Charly takes her wooden desk chair, the one her grandfather used to sit in while he drew cartoons for the daily newspaper, and throws it at the wall. The chair leaves a sizable dent. She grabs the chair again and beats it in the same spot until the wall caves in, holding the chair hostage in the drywall. She yanks on it a couple of times before one of the legs comes off and she stumbles backwards, bumping into her bedside table that has her family lamp. Holding the leg chair like a baseball bat, Charly swings at the porcelain lamp and sends it flying across the room in pieces. A few chunks fall limply on the floor while others rain on the window. Take that, Charly says, letting out a breath she doesnt realize she is holding. A knock sounds against the door. Charly? It is her . Are you okay in there? Charly doesnt say anything back. She slides her hand up and down the wooden leg until a fiveinch splinter catches her at just the right angle. She cries out in pain, dropping the chair leg onto her foot then kicking it at her closet door, watching it bounce off harmlessly. J. Tillman 58 Charly? she says with more urgency. Open the door. The door handle jiggles. Charly says nothing and focuses her attention on the splinter. She tries to push it out upwards, but the splinter pushes in more and breaks off into a thorn further under the skin than she can reach to get it out. She cries out again and swings her hand around to get rid of the pain. Charlotte! The door bows a little bit as she tries to force it open with her small model frame. Charly needs out. She sees the chainlink fire escape ladder lying on the floor next to her windowsher mother had insisted that she have one in case something ever happened, especially with her door constantly locking her in and out of her room. She pulls open one of the windows, pops the screen out and attaches the ladder. Rapunzel lets down her golden hair, Charly says. The chainlinked ladder clatters down the plastic siding of the house. Theres more banging on the bedroom door her fathers voice adds into the mix. Because Rapunzel can save herself and choose her own life. Charly scampers down the ladder, the thorn sliding further into her hands as a drill squeals and the door handle jiggles. Jumping off the last two rungs onto the frost covered grass, a chill runs up her spine the drill still sounding in her now abandoned room. She clutches her splintered hand to her chest and bolts towards the road her house sits next to, crossing into the neighbors yard. The family of four sits at the dinner table, the mother and father smiling at each other while the children laugh and the dog sits patiently next to the table, waiting for food to drop. Charly looks longingly at the family before turning back to her prison tower, run by the evil queen and the corrupted king. She J. Tillman 59 has to escape. She wants what she cant have, what is right on the other side of the door to another house. She holds back the tears that form in the corners of her eyes and takes a deep, steadying breath. She wanted something she couldnt have. She begins to walk down the road, away from home. Cars drive past in the dark, their headlights blinding her, but she keeps moving further down the road, ignoring the world around her. Her name is called and she jumps, looking behind her. It is her father, but the house isnt in sight. She pads her way across the cold concrete into the woods as her fathers voice echoes in the air again. Charly freezes in the underbrush, barely breathing in case it her foggy breath could give her away. As she looks down the road near her house, she sees the twins running around the yard. Robert seemed frantic to find his sister but Louie stares at the ground in front of him and doesnt move. She abandoned her brother when she always told him and his other half, Louie, she would be there for them. She left, not thinking twice about her actions and letting her emotions get the best of her. Charly almost gives in to the temptation of going back and comforting her brother, taking the consequences of her actions Charly! her dad shouts to her, almost snarling, making Charly shrink back into the underbrush, even though Dad is a hundred feet or so away from her on the other side of the road. Charly! he shouts again, running into the road and looking around for her. Charly swears that he sees her as he walks past. Ed! Tasha runs up behind Dad, her small heels clicking venomously on the asphalt. Did you find her? she asks. J. Tillman 60 Does it look like I found her? Dad spits back. How the fuck am I supposed to know? Tasha stands with her hands on her hips. I told you to wait until Ian was able to come down and keep her calm. Who knows when that would be with his football schedule and ridiculous practice times. Besides, the realtor puts the sign in tomorrow. Thought it would be better to tell them, Dad says. I knew something like this would happen. Oh, that my daughter would go bat shit crazy and run off into the woods? Cause that one threw me for a loop. Shes always been crazy. Her only comfort is this area and you just broke that. Now she is going to be a shit bag until she stops coming up and I know that will break you. My daughter isnt allowed to stop visiting until she is an adult, Dad says, flipping off a car that honked at him for standing in the middle of the road. In the noise, Charly shrinks back so she cant see her dad arguing with Tasha, but she can hear them. They didnt notice the extra noise. Yeah, tell me how that one goes. Shes fucking crazy, okay? There is something wrong with her in the head. You need to call the police before she does something that could be dangerous to herself or others, Tasha says, her heels clicking again faintly further away from where Charly sat. I cant file a missing person report for an entire 24 hours. Shes fine. Shell be home in a few hours. And when that happens, I expect an apology. Dads footsteps faint J. Tillman 61 away and Charly sits with her knees curled up to her chest and rocking slowly back and forth as the sun begins to sit in the sky. I refuse to go home. I dont want to be anywhere where she is. Charly stands before she races further into the forest, heading south before turning north in case anyone was following her. The oak trees scratch her exposed arms and legs while she escapes further into the forest, maples dropping leaves on her this October night, a time when people dream about pumpkins, candy, and monsters. It begins to rain. A gnarled old tree stands in front of her with low lying branches and dense leaves to hide anyone inside. She tries to climb up using both hands, but the added pressure doesnt go well with the thorn, so she hauls herself up with one hand and a set of fingers to grip smaller branches. The thick layer of leaves keeps Charly mostly dry, but the wind whips through and makes her skin prickle with goose bumps. Once she is sure no one is behind her, she slowly climbs down the tree. Her soft feet became bloody and raw from her wandering, so she stops, sitting on a fallen tree that connects both sides of a small creek together, her wet hair plastered to her face and thunder clashing over head. I just want a happy ending, Charly says, begging the sky and wishing on the second star on the right. *** A few hours go by as she sits there. The storm passes and Charly doesnt move, her clothes starting to dry off. I cant go back, she says out loud, picking at the skin around the splinter to try and get the thorn out. They dont understand. J. Tillman 62 Leaves rustle behind her, followed by a dog bark. Charly turns too fast and falls off of the tree stump into the slightly swollen creek, getting her clothes wet again. A wet nose touches her knee and Charly sees a pit bull staring at her. Her heart begins to beat faster and she starts to back away slowly before the dog cocks its head to the side and let its tongue loll out, drool sliding off the tip onto Charlys foot. It sits down and remains silent, staring curiously at the girl in the creek. She looks at the dog before leaning forward and reaching out a hand to pet it, cooing to it as she did so. Its okay, boy. I wont hurt you. The dog leans forward towards her, making Charly flinch slightly before she feels soft fur in her hand. She looks and sees the dogs head nestled in her hand, its eyes shut and leaning into Charlys hand. She pets the dog more and brings herself closer to him, checking his collar for a name. Hey Bubba, she says, smiling as she gets a lick on the cheek in response. She pets him with both hands and then gives him a hug. When she pulls away, he licks her injured hand and stands up, taking a few steps away from Charly and looking back over his shoulder. Where are you going? Charly asks, standing up, watching Bubba take a few more steps away from her and stopping to look at her again. She follows the dog, curious to where she is headed. They head further into the forest, just the two of them walking side by side. Every once in awhile they come to the edge of the woods, peering into the houses and seeing families inside, gathering around the TV, the fireplace, or the kitchen J. Tillman 63 table carving a pumpkin. Laughter fills the air as windows are open to let in the cool breeze after the storm. After a few houses, Charly stops, Bubba looking at her curiously. I cant keep doing this, she says. Bubbas tongue lolls out of his mouth. I cant keep saying that things will change and go back to normal. They wont. Charly falls to her knees in front of Bubba. He pulls his tongue back into his mouth tilts his head to the left, looking at Charly as she begins to cry. Dad is leaving and I cant stop him. Charly buries her head into Bubbas neck as Bubba licks her ear to try and calm her down. She continues to cry with Bubba for another minute or so before she straightens up and looks around, finding a small hollow at the base of a willow tree just a few feet from her. She crawls over to the hollow and curls up inside, deciding that she needed sleep, but didnt want to go back to the house. Bubba curled up next to her and together they fell asleep under the tree, leaves rustling in the gentle breeze and falling to hide Charly in her new home. *** Chills run up Charlys spine that wake her out of her sleep. Her body sits covered in goose bumps, her feet are a deep shade of purple, and her fingers refuse to move. Bubba stirs next to her and uses his body heat to try and warm Charly up, but nothing seems to help. Bubba then nudges Charly out from under the tree and starts guiding her east, stopping occasionally to lick her fingers and toes to warm them up a bit. Soon, she sees lights to a house and hangs back while Bubba keeps moving forward. He barks at her, but she steps backwards and hides behind a cluster of trees Bubbas bark has caused movement on the back porch in the morning fog. J. Tillman 64 There you are boy! What did I tell you about running off into the forest? Its dangerous in there for you. A boy around Charlys age comes and attaches a leash to the dogs collar. Bubba doesnt move he sits still and looks over his shoulder. The boy tugs a bit more, but Bubba doesnt move. Bubba, whats wrong? The dog stands up and begins to walk towards Charly, who tries to make herself smaller as the boy looks around the group of trees she is hiding in. Bubba comes and sits next to Charly while the boy stares at her from up above. She reaches out and pets Bubba, who gives her a lick on the cheek in return. Hello. Charly glances up at the boy and shrugs her shoulders, focusing on the spotted pattern on Bubbas back. Im Justin. Charly. Its nice to meet you, Charly. I see you have already met Bubba. The dog smiles. What are you doing in the forest? It looks like youve been out here for a while. Justin motions to her. She shrugs her shoulders again. The three of them sit in silence, Bubba panting between Charly and Justin as the wind makes the trees creak. Why are you in the forest this early in the morning? Justin asks. I ran away, Charly says after a few moments. Why? My dad is replacing me with someone else. J. Tillman 65 Justin gives her a quizzical look, but shrugs his shoulders. Well, I can take you back to my place. Lots of food and clean clothes. Those sound good? Charly nods as her stomach grumbles. Justin stands and sticks out his hand for her to take, but she ignores it, standing up herself and keeping her hand tucked close to her chest, not letting Justin see the thorn or her frozen hands. She is terrified for some reason of what Justin would do if he found out about it. Plus, she doesnt like people feeling sorry for her her mother already did enough of that. No one else needs to worry about poor, little Miss Charly who is incredibly capable of taking care of herself, thank you very much. Justin still pulls Charly to her feet by grabbing her arm, even after she ignores his help. They look at each other for a brief moment before Charly looks down at her feet, pink rising to her cheeks and warmth growing in her stomach. Justin laughs nervously before letting her arm go and walking away, gesturing for her to follow. They walk in silence until a small house with a wooden deck comes back into view. This is home, Justin says as he walks up the steps of the deck to the back door. Bubba pushes Charly along her hand still clutched to her chest. Mom! Do we still have bacon from dinner last night? Justin yells as he walks into the kitchen, Charly standing at the back door. No, you ate the rest of it this morning for breakfast. You still hungry? A woman the same age as Charlys mother emerges from the hallway and stops midstep to stare at J. Tillman 66 the dirt covered girl in her house. Justin! she calls, not taking her eyes off of Charly. Justin walks up next to his mother, a banana hanging out of his mouth. Oh. Mom, he says after swallowing. This is Charly. She was wandering around the woods, saying she was lost and hungry. Charly almost protests because she is definitely not lost her house sits across the street. But Justin winks at her and she smiles a little bit, trusting him almost automatically, even though her instincts are screaming that no one could ever be trusted again. Yet she trusted this newcomer so easily. Why? Her stomach grows warm again and she stares down at her bloody and frozen feet, thinking about Justin. Justins mother is still a bit wary of Charly, but she shakes her head and smiles, stepping forward and crouching in front of Charly. Are you lost? Kara, Justins mom, asks. Charly nods yes. Do you have a family? Shoulders shrug in response. Are you hungry? Charlys stomach growls before she says anything. Justin and Kara laugh and lead Charly to the kitchen of this new kingdom, exactly like the one she wants. Well, Charly, Justin says. What do wanna eat? He throws open the fridge doors dramatically, earning a giggle from Charly, her cheeks becoming a permanent shade of pink around her new friend, an idea that has become foreign to her in recent years. J. Tillman 67 Honey, dont overwhelm her. Ill just toast some bread and scramble eggs. Does that sound good? Kara asks Charly. She nods again. Also, Kara speaks to Justin, go get a few blankets and a sweatshirt of yours. Okay. Justin closes the fridge doors and runs down the hallway, disappearing into another room. Charly stands awkwardly in the kitchen as Kara starts cracking eggs into a bowl. Excuse me, Charly says. Kara turns to look down at her from her intimidating height. Wheres the bathroom? Kara smiles and leads Charly down the hall to a small, closetsized bathroom. Here we are. Just holler if you need anything. Thank you, Charly says as Kara shuts the door to leave the small girl in peace. Charly sighs and looks down at her hand. She struggles to unfold her right hand her fingers slow to respond to her wants but she is able to get ahold of a larger chunk of skin near the thorn. She tugs slowly on it and pain make her eyes black out for a second. She sways slightly before stumbling to sit on the toilet. Bubba pads to the outside of the door and whines quietly. Charly gives another tentative pull, receiving the same reaction. She grinds her teeth together, fingering the skin before tugging up on it quickly, pulling live skin away and exposing the thorn, blood oozing from her hand. She gives a small cry, clenching her hand to her chest and biting her lip, almost putting a hole through it. Bubba barks loudly, his voice echoing in the small hallway. J. Tillman 68 Bubba, dont shout, Justin says before knocking on the door. Charly? You all right in there? Charly cant form words from the pain, but she tries to shrink away into the side of the toilet next to the wall. The toilet brush and plunger clatter around but she doesnt care. She only wants to disappear for a while, maybe forever. Charly? Justin asked again, sounding concerned. Charly shifts and accidentally pushes the thorn further into her hand after almost getting it out. She cries out in pain, kicking the toilet paper holder into the wall and slipping so her head hit the toilet. Charly! Justin shouts, opening the door, Bubba barking wildly, pushing past him and over to Charly. Charly and Justin make eye contact before Charly hides her face in shame. It isnt until Kara comes into the bathroom that Charly starts to cry. Kara pulls Charly out from behind the toilet before she notices the thorn sticking out of her right hand. Kara takes Charlys hands in hers and sees that they are riddled with cuts and scrapes as well. Kara has pity in her eyes for such a young girl in so much pain. Charly is taken aback by this look and cries harder. Charlie thought the family would be incredibly upset by her injuries that she would rather have gone without the function of her hands than ask for help. Justin, get me some old towels. Kara pulls Charly closer to her, cuddling and petting the girls ratty hair, Charly crying into her chest as she let the emotion and the pain out she has kept in for a long time. Justin returns with towels and Kara wraps Charlys hands in them before pulling her to her feet and leading Charly out to the car. The ride remains in strained silence J. Tillman 69 except for Charlys whimpers and sniffling. As they pull into the parking lot, Charly finally speaks. Call my mom. Kara turns around. Whats her phone number? 3175551274, Charly recites from memory. What about your dad? Whats his number? I dont have a dad, Charly says after a moments hesitation. Kara nods and helps Charly into a wheelchair before going to the receptionist to get Charly checked in. Kara explains the situation and Justin sits next to Charly, placing his hand over her towelwrapped ones. Its gonna be all right, I promise, he says. Charly nods. Whats your moms name? Kara asks, typing numbers into her phone. Amanda Stephens. When Kara walks away to call Charlys mom, a nurse comes over to the children. My name is Laura. Im going to ask you a few questions, okay? Charly nods again and tells the nurse her full name is Charlotte Ann Stephens and that she had gotten the huge splinter from the end of a broken chair while destroying her room. Charly refuses to look at anyone when the nurse unwraps her hands to see the thorn. They are quickly wrapped backup. Well take her in right away. Has family been contacted? Her mother is on the way. I just got off the phone with her, Kara says, rejoining the group. J. Tillman 70 Okay, Ill take her back to get started on removing the splinter. Come this way please, the nurse says. She changes, has an IV tube connected to her arm, and her hands are swollen from the thorn and the cold when Justin enters the room. The pair look at each other but say nothing. He only sits in a chair pulled up next to her bed and places his hands on her shoulder where she wouldnt be hurt by his touch. I dont have a dad either, Justin says as Kara and the nurse talk quietly outside the door of the room. He left before I started school. Its just been me and mom. Plus Bubba, of course. Things werent crazy? Charly asks, looking at Justin. Well, yeah. It was just Mom and me. It was a lot better. There was less fighting and yelling. I wasnt scared anymore. Im scared though, Charly mumbles. It gets better. Thank you, Justin, Charly says, giving him her first genuine smile. He returns her smile with a wink and nods his head. *** It takes thirty minutes for Charlys mom to arrive at the hospital. By that point, the thorn is removed and Charly is all patched up. Mom jogs into the room, heels clicking on the linoleum. Charly, sweetheart, she sighs, embracing her daughter as gently as possible. Are you alright? Yes. J. Tillman 71 Kara pulls Mom aside to explain the situation as the doctors say that Charly is good to go home, but shouldnt do anything crazy for the next three weeks while her hands heal. And with the way her hand is bandaged, she cant write since shes lefthanded. Mom drives Charly home, leaving Justin and Kara waving at the entrance doors, promising to visit. Once home and in bed, Charly hears the front door open, followed by thundering feet. The door opens quickly to let two nineyearold boys in the room before shutting again, voices yelling behind it. Charly! Robert says, crawling into bed with her before anyone could stop him. Hi, Charly says, moving herself to give Robert a little bit more room in bed with her. Louie sits at the end of the bed, looking at Charly briefly before he pulls out a battered Gameboy Advanced and plays a game silently, ignoring the world. Why did you run away? Robert asks. Charly remains silent, only shrugging her shoulders and placing her cheek on his head. After a few minutes the yelling stops. Her dad entered the room, with Mom close behind. Charly holds back a cry as her father sits next to the bed. Hey there, kiddo, he says, brushing hair behind her ear. She jerks her head away and stares at the opposite wall. Why did you run away? he asks. Go away, she whispers, rolling away from him and facing the wall and Robert. J. Tillman 72 Charly, whats happened to you? You dont exist anymore. I hate you. Dad sighs and gets up, looking down at Charly in bed and leaves, seeing himself out of the house, the walls shuddering as the door slammed closed. J. Tillman 73 Cash for a Wedding Bachelors beware. Salisvilles sweetheart, Tasha Callow, is now engaged. After a sad break up with her high school sweetheart, Tasha was contacted by an old friend from college, Edward Ed Stephens. IT was love at first site. After two years of dating, the couple is happily engaged, and wedding plans are underway for a fall wedding later this year. Could she be anymore full of herself? Charly asked, throwing down the newspaper that showed a picture of her father and his fianc. Ian stomped into the kitchen, ignoring Charlys outburst against his stepmother, like he normally did when Charly was around. She could get away with saying things around him and not get in trouble for it he didnt like Tasha anymore than Charly did. Shaunda followed closely behind Ian and that was Charlys clue to shut up. If Charly sneezed funny, Shaunda would say something and Charly would be sent to her room as punishment, which is where she wanted to be in the first place. Tasha usually made Charly help her make breakfast on the weekends all the kids were in the cramped house, which meant that Charly made breakfast while Tasha sat on the couch and watched the morning news or reruns of Americas Next Top Model . This Friday morning, Tasha had gone out to WalMart since they were out of eggs and Dad went to work. Charly had still been woken up and asked to make toast for the family, which she did, all buttered up with a shaker of cinnamon sugar on the side of the plate in case anyone cared for it. Ian stood by the fridge, looking at Shaunda like she was some strange being looking up at him with crossed eyes, until he pulled down a package of Pop Tarts for her from the top cabinet, J. Tillman 74 where she couldnt reach and eat them all at once. Charly rolled her eyes, so much for making breakfast. Eight oclock rolled around and Shaunda sat in front of the TV watching cartoons while Charly cooked eggs Tasha had disappeared to her room in the back of the house and Ian had left for a run, conditioning himself for the upcoming fall sports season. The eggs finished scrambling and Charly put them on five different plates, one for each of the kids including herself and one for Tasha even though she didnt eat much, if any. Charly knocked on her brothers door and opened it, flicking on the light and seeing soda cans everywhere with the TV still on. She crossed the room and turned off the TV, pulling blankets off of beds and receiving whines. Breakfast of scrambled eggs and toast is ready. And I want you to throw the cans out before Tasha comes in and yells at you for the mess. Robert mumbled incoherently, rolling a bit too far and falling out of bed onto his back, one leg still in bed. He groaned and picked himself up as Louie covered his head with a pillow. Robert stole the pillow, noticing a large drool stain on it. Dude, you drool in your sleep! Robert shouted, throwing the pillow back and running out the door to the kitchen, Louie stumbling after him. Do not! Louie shouted back. Yeah, Louie doesnt drool! Shaunda shouted from the living room, not taking her eyes off the TV. Enough. You are all ten years old, does it matter who drools and who doesnt? Charly asked, all three of them staring at her. J. Tillman 75 Shaunda shrugged her shoulders and changed the channel, finding Mythbusters far more entertaining than ScoobyDoo . Anyways, breakfast, Charly says, pulling the twins attention back to her. Pick a plate. Dont argue cause its the same amount. I have to go get Tasha because she wanted help with this garage sale thing. Charly left the kitchen and knocked on Tashas bedroom door. There was mumbling and Tasha answered the door with a cami, sweatpants falling off her hips, and still half asleep. Seeing Charly, she pulled up her pants and grabbed a robe off the back of the door. What is it Charly? Its eight. You wanted to open the garage sale at that time. Well, I have a headache, so why dont you do it yourself? Money is in the freezer. Get some cold hard cash. Tasha laughed at her own joke and closed the door. Charly sighed and pulled the money apron out of the freezer before heading to the garage. She opened the door and began displaying the pieces of furniture that her father no longer wanted, even though he brought up from the move. The kids clothes were all hung on racks around the garage and Charly turned on the local radio station, sitting back and beginning to read the last Harry Potter book that had come out six days prior. She sold some of the boys old toys and a couple of outdoor chairs by the time Tasha showed up. She carried a few boxes with her, Ian in towmust have gotten back from his morning run already. They placed the boxes on the table and Tasha opened the lids. Curious, Charly bookmarked her spot and walked over to Tasha, who had stickers labeled $3 in her hand. J. Tillman 76 Inside the three large boxes was Charlys lost VHS collection. She hadnt seen them since the move up north. Where have these been? she asked. In the house, Tasha said. Why didnt you say anything. Ive been looking for these for years. Charly grabbed a box, put the lid on, and tried to take it back into the house. Ian entered the garage again with three more boxes. Thats the last of them, he said before disappearing back inside, refusing to make eye contact with Charly, who pleaded silently with him to back her up on this. Thanks, honey. What did you say Charly? Tasha asked. Ive been looking for my movies for years. I want to take them home. Tasha took the box of movies from Charly and placed them back onto the table. No. They belong to the family, and we no longer need these. She put stickers on them, one by one. Besides, you havent wanted them since your dad moved up here, Tasha argued back. I didnt know they were here. I want to take them back. Charly, please dont argue. Tasha pushed Charly away from the table back towards the chair she had been sitting in. She stared in disbelief before running inside, dialing Dads cellphone number. Hey there, Dad said Dad! she shouted. I found my VHS collection and Tasha wants to sell them. Sorry I cant reach the phone right now, his voice continued. J. Tillman 77 Dad? Charly asked. Leave me a message and Ill get back with ya soon. See ya. Charly hung up the phone and stared at it as it hung on the wall, hoping Dad would call back. The phone remained silent. After a moment, she decided to head back outside. Charly grabbed a few movies and tried to make it back inside, but Tasha grabbed Charlys arm as she was helping the grandma who lived across the street pick out movies. Charly, let go of the movies. We have no way to play them now. Besides, Ed told me to sell them, so let them go. They arent yours, anymore. Charly stopped and let go of the movies, staring at the white garage door for a few seconds, not believing her ears. Dad didnt care about her attachment to those movies. He didnt understand how they seemed to be the last part of her childhood that she remembers being happy. Charly clenched her fists and turned back around, determined to not let her memories disappear. But as she stood next to the freezer filled with deer meat, Tasha sold a giant stack of all of the Disney princess movies, including the straight to VHS releases of Aladdin and Beauty and the Beast to the grandma. My granddaughter is going to love these, she said, and smiled at Tasha. I hope they are loved as much as they used to be here. Tasha said and smiled back. The woman grabbed her paper sack of movies and saw Charly staring dumbstruck at her. Oh, this must be Eds daughter I have heard so much about. Yes, Tasha said, turning around and pulling Charly closer, putting an arm around her shoulders and giving her a side hug. This is Charlotte. She used to watch J. Tillman 78 these movies all the time but outgrew them in favor of Harry Potter, so I want the movies to continue to experience love like they should. Oh my, Harry Potter? The woman gasped, noticing the book in the chair and shaking her head. Do you know that Harry Potter promotes Satanism? I heard, Tasha said back, letting go of Charly and shoving Charly behind her. But if you will excuse me, Mrs. Wilson, I need to go check on my children and make sure that they are up and moving so they dont waste daylight. Well, it was nice catching up with you, Tasha, and congratulations on the engagement. I read about it in the newspaper this morning. Thank you, Tasha said as she disappeared back inside and Mrs. Wilson looked down at Charly. You should be ashamed of yourself for reading such filth. I should take that book and burn it. The Nazis burned books and look where that got them, Charly said before she could stop herself. Mrs. Wilson flushed red. Watch your tongue. Didnt your mother ever teach you manners? Yes, but only to nice people. Not people who buy stolen VHS tapes from children who didnt know their dad and his girlfriend hid them in their room for a year to hope the kids forgot about them. Mrs. Wilson turned pale. She eyed her bag of movies and back at Charly, before turning to walk away. J. Tillman 79 Just be careful, Mrs. Wilson, Charly said, getting a glance from the woman over her shoulder. Mulan doesnt work the best. Shes rather worn when she looks at her reflection. Mrs. Wilson flushed red and she dug in her bag before putting Mulan in her hands and walking away. That was one movie safely in Charlys hands, one she loved as a kid and was the twins first movie they saw in theaters. But Tasha came back out and saw Mulan in Charlys hands and nearly screamed. Did you steal from Mrs. Wilson? No, she gave it back. Said she didnt want it, Charly said. Oh, right, because that totally wasnt the first movie she picked up and was super excited to take home for her granddaughter. No, seriously, she gave it back. What did you say to her? Nothing, Charly lied, staring Tasha down. Tasha looked like she was going to explode, but she calmed herself down as other people came to the garage, looking at the collection of VHS. Fine. You can keep that one and whichever ones dont sell. But, Im sending you to your room. Charly made a grab for Harry Potter, but Tasha snatched it up first. Without Harry Potter, Tasha said, smiling at the shock and terror that crossed Charlys face as her mouth dropped open. Youre gonna catch flies like that. Tasha shut Charlys mouth and leaned back when Charly made a jump for her book. J. Tillman 80 Give it back! Its brand new and I saved up money for two months to buy that myself at the midnight release I dragged my mom to. Charly made another jump at it and Tasha laughed, setting it on top of the cabinet she stood next to. I will if you behave. Inside, now. Tasha snapped her fingers toward the door. Charly looked up at her book on the top of the cabinet and then over at Tasha before taking off the apron and heading inside to her room. She heard Tasha shout for Shaunda, no doubt telling her to watch Charly and make sure she stayed in her room. From the window in Charlys room, she watched as more of her movies left in the hands of others. She had already read every single book in her room and the book she wanted to continue to read was currently stuck in the garage. She paced back and forth, wanting to take things and destroy them, but her right hand would tingle at the memory of last years escape and how she got a thorn in her hand. Hours ticked by and at one point Ian brought her a sandwich and had managed to snag her book back from Tasha. Charly smiled in thanks and Ian left. She ate and continued to read, occasionally looking out the window and seeing more movies leave. At noon, Tasha told Charly she could come out of her room, weird since the garage sales usually went until three. Come on, you need to take a shower, Tasha said. Why? Were going out to a nice place tonight and you need to look your best. You can even borrow one of my old dresses. It might fit you. Tasha left and Charly grabbed what she needed to take a shower. Once out, she ventured into Tashas closet and looked J. Tillman 81 around at the super skinny clothing. None of this was going to fit her, not with her larger chest and wide hips. Charly, these ones on the bed, Tasha said from behind the bathroom door. Looking at the bed were some larger dresses, tags labeled maternity. Charly rolled her eyes and grabbed a dress with blue and green flowers before heading back to her room to put it on and mess with her hair. She left her room and felt naked in the dress. It was tight across her chest, but overly loose around her waist and it came down to her calves, making it look like an old granny dress to her. Shaunda ran around the house in a red dress with her ruby red slippers, Ian wore a button down shirt and a tie. Nice dress, Ian snickered. Charly rolled her eyes and walked to her brothers room, knocking before entering. Louie was taller than Robert at this point, so one of Ians old shirts fit him well enough, and he wore dark jeans since Ians pants were nowhere near the right size. Robert didnt have a shirt to wear, however, and Charly didnt want him to get in trouble for not looking his best. She went back to her room and pulled out one of her button up shirts she wore when she needed to look fancier than necessary. It was still a bit large for Robert and had a feminine shape to it, but when it was tucked into his pants, it wasnt so bad. Robert smiled and hugged Charly, following Louie out into the living room to sit on the couch and wait for everyone else to be ready. Ian stood nervously by the door and Charly sat in the kitchen, waiting to be told what to do next. Tashas voice came from her bedroom. J. Tillman 82 Charly! she shouted. Charly walked over to the door. Would you be a dear and go cut everyone a flower from the backyard? The boys need them pinned to their shirts and you and Shaunda can carry two or three. Sure. Charly went back to the kitchen, grabbed a pair of scissors, and left through the patio out into the backyard to cut flowers. Each of the boys got a purple petunia and she and Shaunda got white lilies. Charly cut a few more for Tasha tiger lilies, and an orange petunia for Dad, because if the kids needed flowers, so did the adults. She headed back inside and had the boys tuck the flower into their shirt pockets. By this point, Dad had returned home early from work and wore a suit and tie, Charly putting the flower through the lapel hole. Whats up? Charly asked. Just getting ready for the wedding, thats all. Dad adjusted his tie I thought the wedding was in September. Didnt Tasha tell you? We closed the garage sale early to go to the courthouse to get married. Spur of the moment thing, since the sale went well. Charly stood still, her hands falling to her side. She should have guessed. Why else would she have to wear a stupid maternity dress and cut flowers from the backyard that shredded all over the place, making it look like she got sneezed on by a bumblebee. Tasha came out in a slinky black dress that hung to her every curve, making a big scene of kissing Dad in the kitchen before heading outside and piling the kids in the car. I called your parents. Theyre on the way. My mom decided to stay home and cook a big meal for us. After the ceremony, because we are cutting it a bit short, Tasha J. Tillman 83 tapped the clock that read 3:49. The courthouse closed at 4 and took three minutes to get there. Mom says she doesnt have any chips, so I told her we would stop by WalMart and pick up a few bags. Sounds good to me, Ed said, bouncing his thumbs on the steering wheel as he sat at a red light, time ticking away. 3:53, they park the car and head inside. 3:55, paid $20 cash for the marriage license. 3:58, wedding performed. 3:59, Ed and Tasha pronounced married. You may kiss the bride. J. Tillman 84 Text Messages April 2, 4:30p.m. Dad: How did your school week finish up Charly? Charly: Fine. Dad: you ready to come up for spring break? Charly: No. Dad: Why not? Charly: I told you. Shelby and I already have plans this weekend to go prom dress shopping and hang out before she visits family in Oklahoma. Dad: And I told you no because we have to prepare for your th grandparents 50 wedding anniversary. Youre on decorations. Charly: Its a gym. Wtf am I supposed to do in a gym, throw glitter around and call it a day? Dad: I told you to come up with something. Youre the artsy one. Charly: Why does everyone say that? Im interested in astronomy, not fucking balloons and streamers. If anything, Robert is more J. Tillman 85 artsy than me! Dad: Charly, watch your language. Charly: w/e Dad: Charly, you will be here tonight. Dad: Charly? Dad: Charlotte Ann, answer me God damn it! Charly: Watch your language. Dad: This isnt funny Charly. _________________________________________ April 2, 4:45p.m. Mom: Ready to go Charly? Charly: Mom, I told you, Im staying with Shelby this weekend. Mom: What did your father say? Charly: No, but Im already over here. Mom: Please dont make things difficult. Charly: Im not going. Mom: Suit yourself. You deal with your own consequences. _________________________________________ April 2, 5:30p.m. Dad: Charly, where are you? J. Tillman 86 Charly: In a black hole. Dad: Charly, why arent you with your brothers? Charly: I told you, Im in a black hole. Dad: Charlotte, this isnt funny. Tell me where you are, Im coming to get you. _________________________________________ April 2, 5:35p.m. Charly: Mom, please tell me Dad isnt coming to pick me up. Mom: Yup. Charly: Dont tell him where I am, please. Mom: Even if I did tell him he wouldnt have listened to me. You know he has been diagnosed with selective hearing disorder. Charly: Mom, did you tell him where Shelby lives? Mom: No, of course not. Charly: Thank you. I love you. Mom: Love you 2 babe. Be safe. Charly: Im invisible. Im safe. _________________________________________ April 2, 5:45p.m. J. Tillman 87 Ed: Where are you? Ed: Charly? Ed: Answer damn it! x2 missed calls Ed: Damn it Charlotte, we are all heading up north, now. Ed: Stop ignoring me Charlotte. Ed: Fine, you come up Sunday. Thats an order. You do NOT want to disobey me again, you hear?! _________________________________________ April 2, 8:03p.m. Evil Queen: Hey Charly, where are you? Evil Queen: I thought you were coming up with your brothers. Evil Queen: Shaunda was excited to see you. Evil Queen: We cant decorate without your artistic eye. Evil Queen: Its lonely without you. Evil Queen: Please stop ignoring me. Its rude. J. Tillman 88 Evil Queen: Charly? Evil Queen: Chaaaaarrrlyyyyyyy! Evil Queen: Charlotte this isnt funny anymore. Answer your phone. x1 missed call Evil Queen: Charlotte, answer your phone. x2 missed calls _________________________________________ April 2, 8:23p.m. Ed: Stop ignoring you mother. Charly: Shes my stepmom. Not my mother. Ed: Dont use that tone of voice with me kid. She is your mother. Charly: No. Ed: We will have a discussion about this later, but your attitude has gotten you into a lot of trouble missy. Charly: Ooo, Im soooo scared. _________________________________________ April 3, 12:56p.m. Charly: Hey Mom, I locked my keys in the car. Can you bring the spare set? J. Tillman 89 Verizon Support: Were sorry, this # has been disconnected. Charly: Mom, this isnt funny. Verizon Support: Were sorry, this # has been disconnected. _________________________________________ April 3, 1:04p.m. Charly: Dad, did you disconnect my phone? I cant get ahold of Mom. Verizon Support: Were sorry, this # has been disconnected. Charly: You fucking serious right now? You are a mother fucking asshole, you know that right? Verizon Support: Were sorry, this # has been disconnected. _________________________________________ April 3, 1:11p.m. Charly: Hey bitch! You fucking Evil Queen. I hate everything about you. Go jump off a fucking cliff you motherfucking piece of shit. And shove a stick up your J. Tillman 90 ass while youre at it. Verizon Support: Were sorry, this # has been disconnected. Charly: Suck it. Verizon Support: Were sorry, this # has been disconnected. _________________________________________ April 3, 1:15p.m. Shelby: Hey Miss Stephens, Charly accidentally locked her keys in the car when we went to Qdoba. Could you bring the spare set? Miss Stephens: Did she lock her phone in the car too? Shelby: No, just the keys. Amanda: Why didnt she call me then. Shelby: Hey Mom, its Charly. Dad disconnected my phone because he called her my mother and I said no and we argued. Now were stranded at Qdoba, not too bad but I dont have a working phone. Amanda: That fucking asshole. Shelby: Tell me about it. Amanda: Ill bring the spare keys and well get you on my plan. He cant do that. What if it had J. Tillman 91 been a real emergency and you couldnt even contact the authorities and you were by yourself? I dont want to think about it right now. Ive had enough of his crap. Shelby: Thank you. Ill buy you a burrito Amanda: Steak queso burrito with sour cream and guacamole please. Thank you. _________________________________________ April 3, 1:24p.m. Amanda: Why did you shut off Charlys phone? Ed: She has no right to speak to me or my wife the way she did. Amanda: Fine, but you cant shut off her phone. That is the only way she could get a hold of anyone. Ed: She can go a few days without a cellphone. She did for almost 16 years. Amanda: No. What if there was an emergency? Ed: Nothing bad is gonna happen. Nothing ever happens in your quiet suburban neighborhood. Amanda: No, Ed. Stuff happens. Charly locked her J. Tillman 92 keys in the car. She couldnt get a hold of me and had to use Shelbys phone to text me. Ed: Well, if she had come up here with me and the boys on Friday, this wouldnt have happened. Amanda: That is beside the point. Sure, it was just a pair of locked keys. But what if it had been something worse? You cant disconnect her phone. Ed: Shell get it back after we talk about her attitude tomorrow after the anniversary party. Amanda: No, not with her driving herself 2 hours north alone. Amanda: You know what, just get rid of her number. Im putting her on my phone plan with the boys, even though you agreed to keep her on your plan so it wasnt so much of a burden for me. Not like you really care about me or the kids. Ed: That doesnt teach her her lesson. Amanda: Well, its good to know youre more interested in punishing our children rather than making sure theyre safe. Ed: You were always the pushover. No wonder the children are unruly. J. Tillman 93 They dont have any discipline. Amanda: Edward, theyre just children. Ed: Theyre teenagers, almost young adults. They need to behave. Its a good thing I got out when I did. I wouldnt let the children be unruly with a bad mother such as yourself and all. _________________________________________ April 3, 3:43p.m. Charly: Hey Robert, its Charly. Had to get a new phone number because Dad cancelled mine. But dont tell him please. Robert: Okay. Hes super pissed. Charly: I know and I dont care. Robert: Hes scaring me. Charly: If anything happens to you or Louie, call the cops okay? Robert: Now youre scaring me. Charly: Im sorry bud. I just dont want anything bad to happen to you guys. I would never forgive myself. Robert: I know, but dont worry. Were fine. Im currently throwing glitter all over the J. Tillman 94 gym cause Dad told me to. Said it was your idea. Charly: I was being fucking sarcastic. Geez. Robert: Lol Robert: Hey, Aunt Faye is here and wants your new number. Charly: Awesome, give it to her! _________________________________________ April 3, 3:54p.m. (502)5552712: Hows my favorite niece. I noticed you werent here. Charly: Im blowing off your brother. <>Aunt Faye: Uh oh, what now? Charly: He wont let me be a normal teenager on spring break where I hang out with my only friend, my boyfriend, go to movies, and prom dress shopping. Aunt Faye: Idk what to say then. Youve been complaining about him to me since you got an email address five years ago or so. He doesnt change. But are you still coming up? I really want to see you and so do your grandparents. Theyve been harassing me J. Tillman 95 about you since I arrived here from Louisville. Charly: . Aunt Faye: ??? Charly: Ill come up Sunday for the party Aunt Faye: Thats the spirit. Charly: But Im sticking to you the whole time like glue. I dont want to mess with Dad. Too much. Aunt Faye: Dont worry, I wont let go of you. I would love it if the bf came along as well ) Charly: We shall see Aunt Faye: XD _________________________________________ April 3, 4:14p.m. Charly: Hey Justin. Its Charly. Got a new number. Asshole shut off the other one. Prince Charming: Why hello there my princess. Charly: I have a question. Prince Charming: Whats up? J. Tillman 96 Charly: I promised my aunt I would go to the party for my grandparents anniversary, so do you wanna come with me? Prince Charming: I thought you were avoiding the party like the black plague? Charly: I was, but I havent seen my aunt since my parents divorce seven years ago and the party is about my grandparents, not my dad. He can shove a stick up his ass for all I care. Prince Charming: You sure this is the right thing to do, not for your family but for you? Prince Charming: . Charly: . Charly: Yes Prince Charming: Alright, Ill drive. Charly: Thank you. I love you. Prince Charming: I love you too, always. Charly: :D _________________________________________ April 3, 7:28p.m. Dad: Is your sister finally coming up? I know youve been texting her. J. Tillman 97 Robert: Yes, she and Justin are on their way up. Dad: Whos Justin? Robert: Charlys boyfriend. Dad: Oh, that guy. Give me Charlys phone number, I need to get a hold of her. Robert: Im not allowed to do that. Dad: Why? Robert: Sisters orders. Dad: Im your father. Robert: And shes my sister. _________________________________________ April 3, 7:32p.m. Ed: Have you heard from Charly? You two text all the fucking time. Faye: Yeah. She and her bf are coming up tomorrow. Ed: The boyfriend wasnt invited. Faye: I went ahead and invited him. Ed: Why? We only planned on a hundred people or so Faye: So whats one more person? J. Tillman 98 Ed: A big deal. Faye: Hes not gonna eat everything. Ed: and what if he does? Faye: Then you dont have to worry about the left overs. What, no retort from that, baby brother? Ed: You always do things behind my back. Faye: Because I know you wont do things that need to be done. Ed: This is about Mom and Dad, not you. Faye: I know. I invited Justin because Mom wont get off my back about him and when she is finally going to meet him. Ed: I hate you. Faye: The hate is mutual baby brother. _________________________________________ April 3, 10:08p.m. Aunt Faye: Your dads an asshole. Charly: Tell me something I dont know. _________________________________________ April 4, 12:11p.m. Prince Charming: What was the whole point of this event again? J. Tillman 99 th Charly: My grandparents 50 wedding anniversary Prince Charming: So why has it become the Tasha and Ed show? Charly: Cause everything is about them Prince Charming: Have I ever told you I hate your stepsister? Charly: Join the club. _________________________________________ April 4, 4:47p.m. Dad: Guys, get off your phones. Its picture time Louie: Coming Robert: Im in the bathroom Charly: Im standing next to you, Dad. _________________________________________ April 4, 5:03p.m. Dad: I do not appreciate the behavior you have displayed here today. Today was about your grandparents and you did nothing but hang out on your phones and ignore the rest of the family and friends here to support them. Louie: I talked with grandma for most of the day! J. Tillman 100 Robert: Aunt Faye is pretty cool. Dad: Still, unappreciated behavior. Charly: whatever. Its better than the Tasha show. Dad: CHARLY! Charly: Come at me. Im 18, I technically dont have to be here. But I came for my grandparents and for Aunt Faye. I came because I love them. I didnt come for you or your model wife. You guys mean nothing to me. I hope you understand this is the last time Ill be seeing you. Dad: I dont appreciate your tone. Charly: I dont care. _________________________________________ April 4, 5:37p.m. Charly: It was great to see you again Aunt Faye Aunt Faye: You too Charly. Charly: Justin and I are heading home. Aunt Faye: Leaving me to calm down your father. Charly: If you want. Aunt Faye: what did you say to him. Charly: FWD: Come at me. Im 18, I technically J. Tillman 101 dont have to be here. But I came for my grandparents and for Aunt Faye. I came because I love them. I didnt come for you or your model wife. You guys mean nothing to me. I hope you understand this is the last time Ill be seeing you. Aunt Faye: Fair enough. _________________________________________ April 4, 5:33p.m. Faye: Youre an asshole. Ed: What did I do this time? Faye: You drove away your daughter. Ed: Shes just having a bad day, thats all. Faye: No. She has felt this way for years. Ed: And how would you know? Faye: theres this little thing called an email that you refuse to answer that I use to talk with Charly over these past few years youve been running around with shebitch. Ed: That is no way to talk about Tasha! Faye: Face it Ed. I dont like her, Charly doesnt like her, the twins dont like her, our parents dont like her. Hell, Charly told me that her son doesnt J. Tillman 102 even like her. You have effectively ruined your relationship with the rest of the family, and I hope you like the bed you made cause you gotta sleep in it now. _________________________________________ April 4, 7:23p.m. Charly: Thank you for coming up with me today. Prince Charming: Any time princess Charly: It was rough, but I hope you had fun. Prince Charming: Just think. You and I leave for IU in 5 months where we get to start over new. No more Ed, no more crazy stepmother and stepsister, just you and me taking on the world. How does that sound. Charly: Sounds like the happy ending Ive been dreaming of Prince Charming: <3 Charly: <3 <3 <3 J. Tillman 103 Appendix B: Welcome to Fallen Crest Outline Part 1 Initial Shock Age 10 Lives in Sunrise neighborhood with her father Edward Ed and mother Amanda, as well as her two twin brothers eightyearold Robert and Louis Louie Normal after school day where Charly gets her homework done early, Robert is sitting in front of the TV watching cartoons, and Louie is complaining about the food. Ed and Amanda enter the room and sit the kids down at the table Describe that for fall break, they will be going down to Louisville to be with their Aunt Faye, Eds only sibling Aunt Faye takes them to Six Flags, Newport Aquarium, and Churchill Downs over their fiveday break Kids return to Sunrise and Amanda has moved to Fallen Crest, but Ed is still at Sunrise. Amanda and Ed explain how they wont be living in the same house anymore, but this has nothing to do with the kids. They will see each parent equally, but they just live in two different houses J. Tillman 104 Louie is confused, as well as Robert, but Charly is visibly upset with tears, but doesnt say anything because she knows what is happening divorce. She thought that this might happen when she had picked up important looking mail but both of their names werent on the envelopes. In December, Amanda has completed the move with the kids to Fallen Crest, right before Christmas everything is now unpacked. (Fallen Crest is lowermiddle class area (older area in Fishers, but not cheapest/shittiest area in the Indianapolis area) Amanda tries her best to hide her depression in the holiday season, but the children do notice, especially Charly, who doesnt ask for an allowance and tries to help her mother out as best as she can Charly even offers to pitch in what little money she does have to buy a few presents for family. Amanda appreciates the move, but refuses, saying the money is for Charly to use. Charly buys her mother DVD player from Goodwill so they can watch movies again, like old times. On Christmas morning, the children have fun just hanging out with their mother, around the tree, and watching a fire crackle on the TV. Door bell rings and Ed shows up. J. Tillman 105 Charly answers the door with Amanda and the twins right behind her Ed invites himself into the house on Christmas morning, ignoring Amandas open glares about intruding uninvited. Gift exchange is made and Ed gets the kids new CD players with no CDs . Amanda gets the kids used books and video games that they will actually play and read. . After kids run off, Amanda and Ed get into an argument over the holiday season and who gets to be Santa . During the argument, the twins find out that Santa isnt real . Amanda kicks Ed out of the house. Ed doesnt even say goodbye Age 11 Summer Ed arrives to pick the kids up for their weekly Wednesday night custody session Tells the kids that they have a special event planned for the night something that never happens Arrive at Ben N Aries Golfing and Arcade on the north side of Indianapolis Fishers Ed Twins introduces a woman and her two children to Charly and the J. Tillman 106 Tasha Ian is the woman, who is just a friend, is the older of the two children (16) and completely uninterested in the whole event Shaunda is an annoying 9yearold miniTasha who is way too interested in the wins for Charlys comfort. They start off the night puttputting Charly hasnt said one word, just waved her hand in hello, but decides to play a round anyways, in silence Twins and Shaunda laugh and giggle while taking crap shots to shoot the golf balls into the various ponds so they can use the net to fish them out Ian is too cool to putput and continuously texts his football friends and girlfriend while sitting on a bench near the arcade entrance. . Charly ends up joining him to get away from Ed and Tasha Tasha weakly hits the balls, so Ed will wrap around her and guide her on how to putt Ed wont leave Tashas side Each attached at the hip and make googoo eyes at each other . Robert and Louie get into a small argument and Robert falls into the water hazard below he cant swim. J. Tillman 107 . Charly runs in and saves her brother from drowning while Ed and Tasha argue with the owner of the arcade about the safety of the place. . Owner throws in free pizza to calm everyone down. Once the kids are calmed down and mostly dried off, they return home and ignore the arcade and duckpin bowling alley. Pizza arrives and . there isnt enough pizza for everyone to eat Charly ends up making more food so that Robert doesnt go hungry with the lack of pizza. . When bedtime comes, the kids split up weirdly for sleeping arrangements and Charly sees Ed kissing Tasha, freaking out because there is no way that her parents could possibly get back together if she played her cards right. . Ian and Charly become acquainted better . But Robert fears that he will lose his sister to Ian like he lost his brother to Shaunda . Charly promises to never leave her baby brother. Age 12 . Summer Ed places the house in Sunrise for sale just under a year after introducing the kids to Tasha and her kids J. Tillman 108 Once Ed decides he is going to move in with Tasha, Charly runs to her room and throws things around. . Upset about the situation but doesnt really know how to handle her anger. Puts holes in the wall (imagining smashing Shaundas pig face in), destroys a desk, and breaks a lamp with a leg from the chair (getting a giant splinter in the palm of her hand). . Once her initial shock subsides and she notices someone trying to open her bedroom door, she escapes down the fire ladder (that Amanda was so insistent Charly had in her second story room) and runs across the street into the small wooded section to try and hide herself, escape from her life and pretend nothing ever happened. . Tries to wake up from a bad dream but cant not dreaming but in reality just wants a happy ending. Charly ends up finding a pit bull named Bubba, who leads her around the woods and protects her from the elements as she stays the night under a hollowed out tree. Bubba leads her to a house where a boy is sitting on the back porch, freaking out about his lost dog. . The boy, Justin, is overjoyed to see his dog, but is also taken aback by Charly, covered in mud and shivering in the morning cold. J. Tillman 109 Justin takes her into the house, where he lives with his mother, and takes care of the girl he found at the edge of the woods Justin runs to get his mom when he sees Charlys splintered hand. They wrap her in a blanket, clean her hands, call Amanda, and take Charly to the hospital to get her hands stitched up . Charly didnt feel any of it since her adrenaline was running, but also wanted to be brave in front of her friend. Amanda arrives at the hospital with the Twins and takes all three of the children home, thanking Justin and his parents for helping their family out. Winter Ed sells the house and moves, but not before fixing it up (finishes basement, paints house, puts up a fence) Never got around to fixing Charlys room Forces her to sleep on guest bed on the loft because of the glass still in her carpet Also easy to monitor her so she doesnt try to escape again like the night she cut her hands and fled to Justins house Wants to keep Charly safe J. Tillman 110 Ed moves in with Tasha in Columbus Trails neighborhood in Fort Wayne, Indiana. Charly gets a room barely bigger than a small walkin closet. Twins share a room with Ian Shaunda gets Ed her own room and Tasha get the master bedroom with attached bathroom The other 5 have to share the other half bath. Christmas Ed and Tasha buy several expensive items because the house was sold They Charly tell kids to not get used to it. gets shitty clothes that are too big and a used GameBoy Color Says Ian on the battery pack on the back Only received Barbie and puzzle games (hates Barbie and the puzzles are too simple) Wanted She Zelda, Mario, and Pokmon games doesnt complain (like she resolves to) because it is the holidays Yeah, she got shit, but the Twins got the goods and they are having a good time Doesnt Age 14 Summer want to ruin that for them J. Tillman 111 Charly has gotten used to living out of a suitcase and having no privacy When the Twins ignore Shaunda, she comes to mess with Charly Knows that she will get a reaction out of Charly Cries and gets Charly in trouble every weekend for not cooperating with Shaunda Most of the time, no one sees Charly She is usually studying and doing homework or reading to stay away from family Discovers old movie collection had been in the attic when Ian brings out boxes to the garage sale Tasha is putting on. Tries . to steal them back, but Tasha stops her. She forces Charly to sell her old movie collection at the next garage sale for three dollars per VHS . Charly is visibly upset and does her best not to cuss out customers . But lets Tasha know her feelings . Also wont let Charly read the newest and final Harry Potter book she had bought herself while selling her childhood away . All about pushing the sale on people, as if it was a retail store rather than a shitty garage sale Day three of the garage sale closes early so Tasha and Ed can go to the court house right before it closed to get married Charly is a bridesmaid J. Tillman 112 Shaunda is the maid Robert is the best man Louie is a Ian Tasha After of honor groomsman is a spectator with his girlfriend and Ed now become Mr. And Mrs. Stevens marriage, they have to go to Walmart before the dinner at Tasha mothers house to grab some last minute ingredients Could it get any more Redneck than this? We close the garage sale early to make it to the courthouse in time so they can get married, and now we have our reception at Walmart because we forgot something or other. Duhhuh. (BanjoKazooi Laugh) Fall Ed and Tasha move the kids to a new house in the richer area of town to Valley Forge neighborhood Each kid can have their own room, but the Twins decide to share a room, so they get the biggest room besides the Master Bedroom on the main floor of the house Have their Ian own TV and bathroom moved off to college back in August, shortly after Tasha and Ed got married He gets the spare bedroom/storage place in the basement when he comes home on breaks J. Tillman 113 Shaunda and Charly have rooms across from one another, also in the basement as well Shaunda has a Charly TV and a new desktop computer has a faulty TV and a semiworking old desktop computer with no desk to put it on or internet to connect it to so she could do her homework. Ed and Tasha say that it was too expensive to route one more cable into Charlys room Just want Charly to spend time with the family as a whole Not always secluded away in her room . Winter . Ed and Tasha want to talk to Charly since she is the oldest in the house now about responsibilities to the house and to the family . Charly isnt having it just fed up about being treated like a child . Ed and Charly go at it in a yelling match . Ed says he didnt have to move You could have said something! I could have stayed at the Sunrise house! . Charly: Oh, like you would have listened to a twelveyearold and a pair of nineyearolds about J. Tillman 114 where you should live. You want me to have responsibilities but you cant even take any blame yourself. The argument ends with Charly being sent to her room Her room is in the basement for a reason to escape, she had to go up the noisy stairs and get past her annoying stepsister Charly discovers she could fit through the half window in the basement and escapes that way Would walk around the neighborhood aimlessly, since she was out of the house. Only got away with it a few times before the police were called to escort her home neighbors worried that she was a stalker or potential predator The window became locked from the inside and outside No Part 2 the quiet years Age 15 Fall more escapes J. Tillman 115 This is the first time Charly requests to stay home for a weekend from Eds High school homecoming freshman year Justin, good friend who found her in the woods, asked her to go with him Ed refuses to let Charly go to some silly event such as Homecoming. Lawrence North High School is on Amandas weekend, so Charly asks Justin if he would like to come to that one instead Ed finds out and strongly encourages Amanda to refuse to let Charly go She would be irresponsibly since she was just like her mother and grandmother Amanda is incredibly offended and openly yelled at Ed on the phone in front of her children because she was so upset To keep the peace in the family, Charly asks Justin to only go out to a small dinner and then to the movies A first date Age 16 Late winter/early spring Ed pays for Charly to take drivers ed so she will be able to drive up to his house so he wont have to drive to pick them up J. Tillman 116 Wont get her a car though or phone thats Amandas job, since she is the custodial parent Charly aces the class and driving obviously with her excessive study habits and unnecessary nerves She ends up getting stranded at school when there is a miscommunication about pickup time after school She gets stuck at school from 4:30 7 after drivers class one day with no way of getting ahold of anyone . . Most students had gone home for the day Has to wait for swim practice parents to show up so she can borrow a phone to call Amanda to pick her up and let her know that she is okay Amanda forces Ed to get her a phone so something like this wont happen again Finally Without gets a phone a car, Charly cant go anywhere Ed gets a phone, but Amanda should get a car Amanda cant afford a car and Ed gets upset he still has to drive to pick up the kids. Part 3 The final blow Age 17 Spring J. Tillman 117 Getting ready for prom season, Charly blows off her dads request to spend her whole spring break with him and Tasha Chooses to Ed stay at friend Shelbys house calls several times along with Tasha, but Charly ignores them, choosing instead to watch stupid movies with Shelby until 3am instead of preparing for her grandparents wedding anniversary party Charly and Shelby spend the next day shopping Both find prom dresses at a resale boutique in Fishers (Havilahs) Lunch at Qdoba, Charly accidentally locks her keys in the car Charly calls Amanda on her phone to get the AAA info to unlock the car. Phone number has been turnedoff Eds way of getting back at Charly for not following instructions He didnt tell anyone, so this took everyone by surprise Shelby calls Amanda about car and Amanda is furious that Charly cant call anyone Tells them the number and the policy ID J. Tillman 118 Amanda calls Ed in a fit of rage but he wont change it until Charly has learned respect for her entire family. Amanda takes an extended lunch break, with her boss and boyfriend Atkins to keep the girls company until AAA can arrive two hours later. After AAA comes, Charly drops off her dress at home and after getting ahold of Aunt Faye, Eds only sister, Charly and Justin travel up to the party. Amanda is barely able to afford the switch, but wants Charly to be able to contact anyone she needs to whenever Atkins pays for the charge fees and Amanda is embarrassed and thankful Charly likes the two of them together and supports her mothers choices Ed and Charly dont speak until after the party the next day, after Justin has returned home because he had to work the next day after the party. Heavy Twins tension between the two know that Charly is going to be in serious trouble and want to protect her since she always protects them and they try to stay by her side, but they are sent to their room and told to not come out no matter what they hear. Charly smiles and says she is going to be fine J. Tillman 119 Your Mother is Poisoning YOU! argument with Tasha no respect for anyone, when they are trying their best to create a loving family Tasha is lying out her ass and Charly knows it, and refuses to take any of this harassment tonight. Charly tries to run out the back door but Ed catches her, drags her, and locks in her room with no phone for the rest of the week, six days After two days, the Twins are able to steal her phone back for her and present her with a new book to keep her entertained before having to go upstairs so they wont raise suspicion Charly contacts Amanda and Justin when she knows that Shaunda isnt in her room and tells them what has happened. Amanda and Atkins are at work, so they cant come get the kids until after Atkins gets out of his legal meeting with a high profile case member. Justin tries to borrow his moms car to come and get her and the twins out of that situation after but cant. Amanda, Atkins, and Justin ride up that afternoon to pick Charly and the Twins up Ed refuses to acknowledge Justin, threatens to punish the Twins for breaking the rules, but gets super enraged that Atkins showed up with Amanda. J. Tillman 120 Thought Charly he had left him in the courtroom pushes Ed to distract him from Atkins, whom she respects immensely Ed tries to push Charly back, but he pushes Justin instead as Justin is trying to get Charly out the door Justin is pushed into the railing and doubles over from stomach pains Charly helps Justin up and out the door Ed is angry drunk, which he has never been before to Charlys knowledge Atkins pulled his lawyer skills to get the kids out of the house temporarily until Ed cleans up for his next weekend with the kids in two weeks The drive home has Charly cuddled in Justins arms, making sure he is alright from being shoved into the banister Summer Charly spends her time bouncing between Amandas, Justins, and Eds Charly is harassed harshly at Eds but she ignores it for the most part Any back talking results in getting sent to her room with no computer and no ability to look at colleges or do homework, which she doesnt want to happen, so she continues to ignore the family to the best of her abilities J. Tillman 121 Charly is also prevented from getting a summer job because of Eds strict schedule that doesnt allow her to work weekends Summer remains calm and hot You could hear a pin drop in a usually noisy house that is Ed and Tashas School Begins/Fall Charly commits herself to her schoolwork and clubs and applying to colleges Wants to look good for college applications Justin joins her for almost all of the clubs when not working out for baseball, varsity team captain offseason workouts (plays shortstop) Amanda and Justin encourage her to go to college Ed doesnt want to pay for it Tasha and Ian dont think she is smart enough for it. Charly is forced to get preapproval from Ed and Tasha about weekends home Approve of academic weekend events, but not games or homecoming J. Tillman 122 On a weekend Charly is home at Amandas, she and Justin are able to attend homecoming and genuinely have a great time He gets her a promise ring and she freaks out and after her small panic attack, they get intimate for the first time Ed disapproves of the ring, but says Charly can just deal with the inevitable teenage pregnancy, just like family history She ignores this statement, but she knows Ed doesnt trust her Sad, thought that there could have been a little glimmer of hope, but she doesnt see any anymore Doesnt care about Ed or his family anymore, they dont care or trust her, she doesnt care or trust them back. Winter Same as in years past: Charly secludes herself in her room to try and create the least amount of conflict Ian and Shaunda praised most with Christmas gifts Twins happy and content with their gifts Charly gets leftovers Charly can only call Justin when either Tasha and Ed are in the room J. Tillman 123 Hides texting Concentrates mostly on homework and the beginning stages of AP studying Finishes applying for colleges A few scattering of wait listing and rejections lower Charlys confidence about being able to go to college Doesnt help with Ian and Tasha say, Told ya so. Age 18 Birthday/Late Ed Winter insists on taking Charly out to lunch on her birthday She Ed Ed, is at an academic conference all day is upset but settles on taking Charly out for dinner Tasha, Shaunda, the Twins, and Charly go to El Rodeo Justin Dinner not allowed to come is alright Charly gets $18 even for her birthday and a pin that says, Im 18, an adult. Respect! Has to put the button on even though she doesnt want to J. Tillman 124 Wears the giant sombrero and is super embarrassed about the whole birthday celebration in general Shaunda has a meltdown about not being the center of attention and makes herself known front and center Still acts like a baby, even though she is a high school freshman Becomes the Shaunda Charly show takes a back seat No energy after the conference and doesnt really care anymore. Charly thanks Ed and Tasha for dinner before she drives the Twins home in Amandas car that she borrowed for dinner Once home, there is Gramma, Shelby, Atkins, and Justin to celebrate and eat cake A few weeks later Ed, Amanda, and Charly all sit down in a neutral area out in the open neighborhood park (with Atkins and the twins still at the house) to discuss college options Ed and Amanda have opposite views and Charly agrees with Amanda setting Ed off Ed is still upset about being abandoned and replaced by Amanda and thinks Amanda has corrupted Charly against him J. Tillman 125 Tasha was right in saying that Amanda was poisoning Charly Charly confronts Ed to say that these decisions are her own and to quit beating up on Amanda and living in the past Ed storms off and says the can bury themselves in debt, its not his problem Spring Charly Early cracks down on studying for AP tests May: Ian graduates from Ohio State Charly She is in the middle of studying for tests that start next week pays attention to Ian graduate with the School of Business, but studies while other students graduate that she doesnt care about Ed thinks Charly isnt paying attention at all Ed emotionally harasses Charly and takes her study books, saying she shouldnt study because it is a waste of time and money Robert, Louie, and Shaunda follow Charly out into the hallway of the auditorium Louie tells Shaunda off and sends her back inside, crying to her mother. J. Tillman 126 Tasha returns to hallway with an evil determined look in her eyes and is going to tell Charly off once and for all, but Charly and the twins have left. Amanda let Charly borrow her car since she didnt have to work on the weekends Plus, Tasha Atkins can drive her runs outside to bring the children inside, but they are already on their way home Charly is ready for the AP tests, and takes them with relative ease From A month Receives . all the studying, Charly remains calm the whole test later, she finishes school with all As a larger scholarship from Indiana University, to study prelaw Thanks to Atkins Receives 4 and 5s on her AP exams in mid July, receiving enough credits to be a college sophomore End of the Summer Movein Day Charly and Justin are in the same dorm building Justin Ed is a computer science major shows up at Amanda house with some items for Charlys dorm room and asks if she needs help moving in He is denied J. Tillman 127 As Charly, the Twins, Amanda, Justin, and his parents get ready to head out, Ed looks rejected This shocks Charly and as much as she has grown to hate this man, she goes and talks to him. There is awkward silence between the two as they dont know what to say to each other Charly extends her hand and gives Ed a genuine smile Ed No shakes her hand and gives her a smile back words are said. Ed gives a content sigh, and Charly nods her head and gets in the car with Justin to head down to Bloomington to begin college, and her new life. J. Tillman 128 Character Age Chart This is a concise table with all of the characters ages displayed in an easy to read format Welcome to Fallen Crest Water Hazard Scars Cash for a Wedding Text Messaging Charly 10 11 12 14 18 Robert 7 8 9 11 15 Louie 7 8 9 11 15 Ian 14 15 16 18 22 Shaunda 7 8 9 11 15 Ed 35 36 37 39 43 Amanda 39 40 41 43 47 Tasha 30 31 32 34 38 Faye 41 42 43 45 49 Year 2003 2004 2005 2007 2011 J. Tillman 129 Character Descriptions Character Sheet adapted from Characters, Emotions, and Viewpoints by Nancy Kress. Each of the following character sheets were created for characters important to the outline but may or may not have been mentioned or developed in the stories themselves. MiniBio for Key Characters Name : Charlotte Charly Ann Stephens Age : 1018 Birthplace : Indianapolis, Indiana Marital Status : single Children and their ages : none General appearance (whatever seems useful) : Blonde, brown eyes, shorter torso/long legs, large chest and wide hips Living arrangements (i.e., lives with wife and three young children rents a ramshackle apartment alone has tent in nomadic tribe with three concubines) : Primarily with mother, visit dad and stepmom on weekends Occupation, including name of employer (if applicable) : Student in the Hamilton Southeastern School District Degree of skill at occupation (beginner, really competent, experienced but a bumbler, etc.) : Competent J. Tillman 130 Characters feelings about their occupation (love it, hate it, regards it as just a job, has mixed feelings, is actively searching for other employment): Pushes for best grades possible it allows for an escape from her family in hard times. Family background (whatever you think is important: ethnicity, siblings names, parents names, social status, clan affiliation, total repugnance toward everybody they knew before the age of 12) : Mother, Father, Twins Robert and Louie, Stepbrother Ian, stepsister Shaunda, stepmother Tasha Emotional MiniBio Name : Charly What three or four things does this person value most in life? (i.e., success, money, family, God, love, integrity, power, peace and quiet) School, friendship, family (specifically mom and twins) What three things do they fear most? Divorce, rejection, being alone/lost/abandoned What is this persons basic underlying attitude about life? (i.e. Things will usually turn out all right, or Theyre all out for themselves, or Its best to expect nothing because then you wont be disappointed, etc.) If you want something done you gotta do it yourself What does this person need to know about someone else in order to accept that others as all right and trustworthy? J. Tillman 131 Doing what they say, being a genuine person What would cause this person more pain than anything else possible? Mistrust/backstabbing, lost loyalty What would this person consider the most wonderful thing that could ever happen to them? Close family and friend motivation and empowerment What three words would they use to describe themselves, accurate or not? Studious, angry, shy How accurate is their selfdescription? Very accurate (but not always as shy as she thinks she is) J. Tillman 132 MiniBio for Key Characters Name : Robert Stephens Age : 715 Birthplace : Indianapolis, Indiana Marital Status : single Children and their ages : none General appearance (whatever seems useful) : Shaggy brown hair, smirky grin, playful brown eyes Living arrangements (i.e., lives with wife and three young children rents a ramshackle apartment alone has tent in nomadic tribe with three concubines) : Stays with Mom during the week, enjoys spending time at Dads almost every weekend, even when it isnt his weekend. Occupation, including name of employer (if applicable) : Student, Hamilton Southeastern School District Degree of skill at occupation (beginner, really competent, experienced but a bumbler, etc.) : More competent than brother Louie Characters feelings about their occupation (love it, hate it, regards it as just a job, has mixed feelings, is actively searching for other employment) : Its neither here nor there, just something he has to do. J. Tillman 133 Family background (whatever you think is important: ethnicity, siblings names, parents names, social status, clan affiliation, total repugnance toward everybody they knew before the age of 12) : Super attached to Charly and twin Louie, will stick to Charly over anyone. Emotional MiniBio Name : Robert What three or four things does this person value most in life? (i.e., success, money, family, God, love, integrity, power, peace and quiet) : Family, music, happiness, life What three things do they fear most? Lose, drowning, darkness What is this persons basic underlying attitude about life? (i.e. Things will usually turn out all right, or Theyre all out for themselves, or Its best to expect nothing because then you wont be disappointed, etc.) : The glass is half full, cause I drank the other half What does this person need to know about someone else in order to accept that others as all right and trustworthy? If Charly and/or Louie (mostly Charly) trust them, then he will too What would cause this person more pain than anything else possible? Seeing Charly get beaten up for protecting him and Louie What would this person consider the most wonderful thing that could ever happen to them? J. Tillman 134 The close family he is in What three words would they use to describe themselves, accurate or not? Mischievous, happygolucky, protector How accurate is their selfdescription? Pretty good J. Tillman 135 MiniBio for Key Characters Name : Louie Louie Stephens Age : 715 Birthplace : Indianapolis, IN Marital Status : single Children and their ages : none General appearance (whatever seems useful) : Blonde hair (Charly), blue eyes (Amanda), rounded ears (Robert), thin lips (Ed) Living arrangements (i.e., lives with wife and three young children rents a ramshackle apartment alone has tent in nomadic tribe with three concubines) : Mom primarily (with Charly and Robert), Dad and stepmom on weekends Occupation, including name of employer (if applicable) : Student, Hamilton Southeastern School District Degree of skill at occupation (beginner, really competent, experienced but a bumbler, etc.) : Moderate learner Characters feelings about their occupation (love it, hate it, regards it as just a job, has mixed feelings, is actively searching for other employment) : Not interested, just wants to leave as soon as possible J. Tillman 136 Family background (whatever you think is important: ethnicity, siblings names, parents names, social status, clan affiliation, total repugnance toward everybody they knew before the age of 12) : Attached to Ed over Amanda (Dad over Mom), Roberts best friend but finds his younger twin to be a bit of a nuisance. Emotional MiniBio Name : Louie What three or four things does this person value most in life? (i.e., success, money, family, God, love, integrity, power, peace and quiet) Peace and quiet, intelligence, family What three things do they fear most? Loneliness, lost, death What is this persons basic underlying attitude about life? (i.e. Things will usually turn out all right, or Theyre all out for themselves, or Its best to expect nothing because then you wont be disappointed, etc.) The glass has water in it What does this person need to know about someone else in order to accept that others as all right and trustworthy? Spends time analyzing behavior and asks several questions for similar answers to his What would cause this person more pain than anything else possible? Losing his twin Robert J. Tillman 137 What would this person consider the most wonderful thing that could ever happen to them? Hasnt happened yet What three words would they use to describe themselves, accurate or not? Smart, aloof, protective How accurate is their selfdescription? Pretty good J. Tillman 138 MiniBio for Key Characters Name : Amanda Stephens Age : 3947 Birthplace : Indianapolis, Indiana Marital Status : divorced Children and their ages : Charly 1018, Robert and Louie 715 General appearance (whatever seems useful) : Same as daughter Charly, slightly taller and more aged/wrinkled face from stress (makes her look older than she actually is) Living arrangements (i.e., lives with wife and three young children rents a ramshackle apartment alone has tent in nomadic tribe with three concubines) : Small threebedroom house with children in a bit of the rundown part of Fishers to keep the kids in the same school district and not disturb their lives more than she and her exhusband already had Occupation, including name of employer (if applicable) : Receptionist at Atkins and Brown paralegal office Degree of skill at occupation (beginner, really competent, experienced but a bumbler, etc.) : Extremely competent want to become a paralegal but has no money (all of it goes to keeping her kids happy, healthy, and safe) J. Tillman 139 Characters feelings about their occupation (love it, hate it, regards it as just a job, has mixed feelings, is actively searching for other employment) : Loves it paralegal Atkins helped with divorce and gave her a job (eventually becoming her boyfriend/lover) Family background (whatever you think is important: ethnicity, siblings names, parents names, social status, clan affiliation, total repugnance toward everybody they knew before the age of 12) : Father died young (of a heart attack), mother even younger raised by grandparents when mother was working to put food on the table Emotional MiniBio Name : Amanda What three or four things does this person value most in life? (i.e., success, money, family, God, love, integrity, power, peace and quiet) Family, trust, love, honor What three things do they fear most? Loss/rejection, harm to loved ones, letting kids go to their fathers and having something happen (paranoia) What is this persons basic underlying attitude about life? (i.e. Things will usually turn out all right, or Theyre all out for themselves, or Its best to expect nothing because then you wont be disappointed, etc.) Family is the most important J. Tillman 140 What does this person need to know about someone else in order to accept that others as all right and trustworthy? Honesty, willingness to help in the face of need What would cause this person more pain than anything else possible? Dishonesty and loss of honor What would this person consider the most wonderful thing that could ever happen to them? Having happy, healthy kids who experience no pain from her ex What three words would they use to describe themselves, accurate or not? Determined, strong, protective (like a mama bear) How accurate is their selfdescription? Incredibly accurate J. Tillman 141 MiniBio for Key Characters Name : Edward Ed Stephens Age : 3543 Birthplace : Fort Wayne, Indiana Marital Status : divorced, remarried Children and their ages : Charly 1018, Robert and Louie 715 General appearance (whatever seems useful) : Short brown hair, scruffy mustache/beard, beer belly, shifty/squinted eyes, wrinkled forehead, thin lips Living arrangements (i.e., lives with wife and three young children rents a ramshackle apartment alone has tent in nomadic tribe with three concubines) : Lives with second wife Tasha and stepdaughter Shaunda with visits from stepson and own children Occupation, including name of employer (if applicable) : Computer programmer at Ace Fixers Degree of skill at occupation (beginner, really competent, experienced but a bumbler, etc.) : Experienced, has learned from past work in the city when he lived with Amanda Characters feelings about their occupation (love it, hate it, regards it as just a job, has mixed feelings, is actively searching for other employment) : J. Tillman 142 Mixed loves computers, just a job but wants to stay because he is committed to making more than enough money for his family Family background (whatever you think is important: ethnicity, siblings names, parents names, social status, clan affiliation, total repugnance toward everybody they knew before the age of 12 ): Small family. Stay at home Mom, community active dad with Associates Degree from small Christian college. Sister Faye left for out of state college and never came back. Now has a sort of distrust for his sister for leaving the family. Emotional MiniBio Name : Ed What three or four things does this person value most in life? (i.e., success, money, family, God, love, integrity, power, peace and quiet) Money, forgiveness, consistency What three things do they fear most? Parental death (wouldnt have anyone to truly trust anymore), bankruptcy, unforgiveness What is this persons basic underlying attitude about life? (i.e. Things will usually turn out all right, or Theyre all out for themselves, or Its best to expect nothing because then you wont be disappointed, etc.) Get get whats coming to you J. Tillman 143 What does this person need to know about someone else in order to accept that others as all right and trustworthy? Same ideas, allowing forgiveness What would cause this person more pain than anything else possible? Not receiving forgiveness for what he claims isnt a big deal What would this person consider the most wonderful thing that could ever happen to them? Marrying Tasha and having the seemingly perfect American life What three words would they use to describe themselves, accurate or not? Efficient, understanding, money conscious How accurate is their selfdescription? Not good. He doesnt understand when peoples perspectives are different than his own and want to argue against him J. Tillman 144 MiniBio for Key Characters Name : Tasha CallowStephens Age : 3038 Birthplace : Fort Wayne, Indiana Marital Status : divorced, remarried Children and their ages : adopted son Ian 1422, biological daughter Shaunda 715 General appearance (whatever seems useful) : Short jetblack hair that she will dye random colors that dont always match her skin tone, super curvy, skinny, sharp nose Living arrangements (i.e., lives with wife and three young children rents a ramshackle apartment alone has tent in nomadic tribe with three concubines) : With Ed and Shaunda, occasionally with Ian, Charly, and the twins Occupation, including name of employer (if applicable) : Local model, Pristine Image (how Ed reconnected with her Degree of skill at occupation (beginner, really competent, experienced but a bumbler, etc.) : Decent (not appealing model face but great body) Characters feelings about their occupation (love it, hate it, regards it as just a job, has mixed feelings, is actively searching for other employment) : Just a job, but not educated to do anything else besides watch TV and exercise excessively J. Tillman 145 Family background (whatever you think is important: ethnicity, siblings names, parents names, social status, clan affiliation, total repugnance toward everybody they knew before the age of 12) : Rich area, spoiled youngest child of five, the perfect image of the American Family Emotional MiniBio Name : Tasha What three or four things does this person value most in life? (i.e., success, money, family, God, love, integrity, power, peace and quiet) Beauty, freedom, cooperation with her ideas What three things do they fear most? Ugliness, rejection, bankruptcy What is this persons basic underlying attitude about life? (i.e. Things will usually turn out all right, or Theyre all out for themselves, or Its best to expect nothing because then you wont be disappointed, etc.) Beauty is all a woman needs What does this person need to know about someone else in order to accept that others as all right and trustworthy? If they praise her beauty What would cause this person more pain than anything else possible? Not being an acceptable model J. Tillman 146 What would this person consider the most wonderful thing that could ever happen to them? Getting back together with her college sweetheart Ed What three words would they use to describe themselves, accurate or not? Beautiful, perfect, cunning/smart How accurate is their selfdescription? Eh, accurate but not for the right reasons. J. Tillman 147 MiniBio for Key Characters Name : Shaunda Callow Age : 715 Birthplace : Auburn, Indiana Marital Status : single Children and their ages : none General appearance (whatever seems useful) : Curly brownishblack hair, mothers brown eyes, short, small waist (almost an exact replica of her mother Tasha) Living arrangements (i.e., lives with wife and three young children rents a ramshackle apartment alone has tent in nomadic tribe with three concubines) : Lives with Ed, Tasha, Ian and sometimes her stepsiblings (but not with her father. She rarely visits him) Occupation, including name of employer (if applicable) : Student, Dekalb County School District Degree of skill at occupation (beginner, really competent, experienced but a bumbler, etc.) : Not really good, more interested in a potential modelling career like her mother Characters feelings about their occupation (love it, hate it, regards it as just a job, has mixed feelings, is actively searching for other employment) : Just school. Would like to follow in her moms footsteps J. Tillman 148 Family background (whatever you think is important: ethnicity, siblings names, parents names, social status, clan affiliation, total repugnance toward everybody they knew before the age of 12) : Super close to Tasha, hardly sees her father, thinks of Ed as a father, completely ignores Ian, super interested in the twins (especially Louie). Jealous of Charlygets her into trouble all the time so she can be the center of attention for the family Emotional MiniBio Name : Shaunda What three or four things does this person value most in life? (i.e., success, money, family, God, love, integrity, power, peace and quiet) Tasha, success, health, beauty What three things do they fear most? Unsuccessful, being fat/ugly, losing Tasha What is this persons basic underlying attitude about life? (i.e. Things will usually turn out all right, or Theyre all out for themselves, or Its best to expect nothing because then you wont be disappointed, etc.) Beauty is the way to a successful life What does this person need to know about someone else in order to accept that others as all right and trustworthy? If Tasha trusts them, she does too What would cause this person more pain than anything else possible? J. Tillman 149 Losing/being rejected by Tasha What would this person consider the most wonderful thing that could ever happen to them? When she decided to follow in Tashas footsteps What three words would they use to describe themselves, accurate or not? Beautiful, kind, smart How accurate is their selfdescription? Not very accurate. Can be bitchy and dumb and definitely not kind. J. Tillman 150 MiniBio for Key Characters Name : Ian Callow Age : 1422 Birthplace : Auburn, Indiana Marital Status : single Children and their ages : none General appearance (whatever seems useful) : Short brown hair, broad chest, muscular football, a bit on the short side Living arrangements (i.e., lives with wife and three young children rents a ramshackle apartment alone has tent in nomadic tribe with three concubines) : Stays with his father most of the time, but visits stepmother Tasha and her husband Ed from time to time, mostly to check up on Charly and make sure she is handling the craziness well. Occupation, including name of employer (if applicable) : Student, Dekalb County School District Ohio State University Degree of skill at occupation (beginner, really competent, experienced but a bumbler, etc.) : Somewhat competent, but lazy and unmotivated to care more and get above the bare minimum for football requirements Characters feelings about their occupation (love it, hate it, regards it as just a job, has mixed feelings, is actively searching for other employment) : J. Tillman 151 Doing it to be first college graduate on the Callow side of the family Family background (whatever you think is important: ethnicity, siblings names, parents names, social status, clan affiliation, total repugnance toward everybody they knew before the age of 12) : Lives with Dad, sees Mom weekly, regular sport practices, in his own bubble of friends and acquaintances. Emotional MiniBio Name : Ian What three or four things does this person value most in life? (i.e., success, money, family, God, love, integrity, power, peace and quiet) Strength, freedom, friendship What three things do they fear most? Weakness, being alone, inability to play sports What is this persons basic underlying attitude about life? (i.e. Things will usually turn out all right, or Theyre all out for themselves, or Its best to expect nothing because then you wont be disappointed, etc.) Sports are life What does this person need to know about someone else in order to accept that others as all right and trustworthy? Nothing, he trusts anyone cause he really doesnt care. If they mess up, they mess up and he moves on with his life What would cause this person more pain than anything else possible? J. Tillman 152 Death What would this person consider the most wonderful thing that could ever happen to them? Going to college for football What three words would they use to describe themselves, accurate or not? Strong, handsome, intelligent How accurate is their selfdescription? Decent definitely not as smart as he thinks he is J. Tillman 153 MiniBio for Key Characters Name : Justin Fincher Age : 1119 Birthplace : Kokomo, Indiana Marital Status : single Children and their ages : none General appearance (whatever seems useful) : Small frame, lean and muscular, blue eyes, gentle smile, constantly winking, shaggy brown hair Living arrangements (i.e., lives with wife and three young children rents a ramshackle apartment alone has tent in nomadic tribe with three concubines) : Lives with single mother and pit bull named Bubba in a quaint ranch house across the road from Eds house (Charlys dad) Occupation, including name of employer (if applicable) : Student, Hamilton Southeastern School district Degree of skill at occupation (beginner, really competent, experienced but a bumbler, etc.) : Moderate learner (knows facts, is just a lazy procrastinator) Characters feelings about their occupation (love it, hate it, regards it as just a job, has mixed feelings, is actively searching for other employment) : Enjoyable J. Tillman 154 Family background (whatever you think is important: ethnicity, siblings names, parents names, social status, clan affiliation, total repugnance toward everybody they knew before the age of 12) : Good family, no problems (other than Dad when he was little, but nothing recently) Emotional MiniBio Name : Justin What three or four things does this person value most in life? (i.e., success, money, family, God, love, integrity, power, peace and quiet) Friends, family, sports, life What three things do they fear most? Loneliness, spiders, not being able to help others What is this persons basic underlying attitude about life? (i.e. Things will usually turn out all right, or Theyre all out for themselves, or Its best to expect nothing because then you wont be disappointed, etc.) I got this, maybe? What does this person need to know about someone else in order to accept that others as all right and trustworthy? Being honest and truthful What would cause this person more pain than anything else possible? Losing anyone while away/being unable to help them J. Tillman 155 What would this person consider the most wonderful thing that could ever happen to them? Charly What three words would they use to describe themselves, accurate or not? Friendly, sporty, huggable How accurate is their selfdescription? Very accurate J. Tillman 156 MiniBio for Key Characters Name : Daniel Atkins Age : 3845 Birthplace : St. Louis, Missouri Marital Status : single Children and their ages : none General appearance (whatever seems useful) : Very well put together, slicked back brown hair, clean shaven, tall, small shoulders and large feet Living arrangements (i.e., lives with wife and three young children rents a ramshackle apartment alone has tent in nomadic tribe with three concubines) : Lives in a 2bedroom apartment by himself, until Amanda (Charly and the twins mother) asks him to move in with the family. Occupation, including name of employer (if applicable) : Paralegal Atkins and Brown law firm (hes a coowner/partner) Degree of skill at occupation (beginner, really competent, experienced but a bumbler, etc.) : Extremely competent Characters feelings about their occupation (love it, hate it, regards it as just a job, has mixed feelings, is actively searching for other employment) : Absolutely loves it J. Tillman 157 Family background (whatever you think is important: ethnicity, siblings names, parents names, social status, clan affiliation, total repugnance toward everybody they knew before the age of 12) : Family moved a lot, now all in different states. Pushed to be a lawyer by his own father (who dropped out of law school), but never found anyone he wanted to settle down with until Amanda and her family, after he defended her in court when she was getting a divorce from her exhusband Ed and offered her a job as a receptionist at his law firm. Emotional MiniBio Name : Atkins What three or four things does this person value most in life? (i.e., success, money, family, God, love, integrity, power, peace and quiet) Smarts, loyalty, consistency, courage What three things do they fear most? Death, never finding a companion, water What is this persons basic underlying attitude about life? (i.e. Things will usually turn out all right, or Theyre all out for themselves, or Its best to expect nothing because then you wont be disappointed, etc.) You can win at almost anything with wit, determination, and skill What does this person need to know about someone else in order to accept that others as all right and trustworthy? Telling the truth J. Tillman 158 What would cause this person more pain than anything else possible? Losing practice/law firm and/or Amanda and her kids What would this person consider the most wonderful thing that could ever happen to them? Amanda and her kids plus his partner Connor Brown What three words would they use to describe themselves, accurate or not? Witty, honest, friendly How accurate is their selfdescription? Alright. Hes more shy than witty J. Tillman 159 Annotated Bibliography Alexie, Sherman. The Lone Ranger and Tonto Fist Fight in Heaven . 20th Anniversary ed. New York: HarperPerennial, 1994. Print. For this collection of short stories, the author has connected the stories together with the same collection of characters at different ages, levels of maturity, and perspectives. Since Sherman Alexie is a Native American who grew up on the Spokane Reservation in Washington state, his characters are based on people he either knew or situations he witnessed or was a part of. This brings an interesting connection to all of the stories while also having each story stand alone each with a distinct beginning, middle, and end. This has been the best collection of stories I have read for my senior English Capstone project and for my honors collection of short stories because of the interconnected stories and how the characters change over time. One part that really stood out to me was the timeline. Not all of the stories were written in chronological order. There is Vincent, the main character through all of the stories, describing a story of his parents and how they had drunk parties to entertain the neighborhood while Vincent was downstairs, followed by another story that describes Vincent going down to Arizona to pick up the ashes of his father that were found in his trailer years after he left his mother, then followed by a third story about a different character hanging out with Vincent back on the reservation to keep him preoccupied while his parents fought and threatened divorce. With the jumbled timeline, it gives the feel that all of the stories are just that, stories. They don't have to be in any order, and I had never thought about that before. J. Tillman 160 Since my project is both for my English Capstone and my honors project, this book has been the best for describing how things can connect together, while not necessarily being in order. This can be a great advantage I can use when drafting the stories as well as deciding their order for the final project. With an interconnected collection of short stories, I had always figured that the stories had to be plotted out in chronological order, since I mainly read novels, and they are plotted out in chronological order. But since these are stand alone stories, I can do whatever I want with each story, from any age, time, and perspective, and create a unique and compelling series of short stories that would not have come about in a novel or linear collection of short stories. This will definitely be an aspect that I bring to my own writing and I will continue to work with in the future. J. Tillman 161 Anderson, Sherwood, with an introduction by Ted Olson. Winesburg, Ohio . New York: Barnes & Noble, Inc., 2010. Print. This book seems to be one of the best collections of interconnected short stories on the market today. Since reading it, it has helped with my writing tremendously. Not just in the way that shows writers how to write a good short story, but how to connect everything together. Sometimes, while writing my own collection, it was hard to make the stories stand by themselves but also be connected to one another, one of the goals of this project. Sherwood Anderson wrote this collection almost one hundred years ago and it still holds up as a formidable collection of stories. Not only is the connection there, but the language and the emotion is present as well. One of my favorite lines is she was like one who has discovered the sweetness of the twisted apples, she could not get her mind fixed again upon the round perfect fruit that is eaten in the city apartments (12). This line, from the story called Paper Pills describes a character who moved to this rural town after having lived in a major city for a while, but returned to her family. Once back, she decided to stay because there are things in small towns that you cannot get anywhere else, and those little things make the best gifts to each person who comes to a small town. It is these intricacies of the stories, and also the central location that make this collection seem incredibly modern and relevant today. The characters are distinguished and express themselves on the page in their own way, which is something I have been trying to do, but do not always seem to make it all the way, or have the characters as unique as they need to be. Anderson has created some great characters and I am going to J. Tillman 162 emulate that in my own writing so my stories are firmly based in reality and can last for long periods of time. J. Tillman 163 Bernheimer, Kate. Mirror, Mirror on the Wall: Women Writers Explore Their Favorite Fairy Tales . New York: Anchor Books, 1998. Print. This book came to me later in this project than previous books that were predetermined before I started writing. For one of my stories I wanted to use a fairy tale motif because the main character wanted to escape what she called her Evil Queen, her fathers girlfriend, soon to be wife. Because I wanted this motif, I needed to do more research on how people write about fairy tales as well as how fairy tales have effected writers from childhood to adulthood. I, myself, have taken a liking to fairy tales since I can remember my mother reading me some watered down versions of Grimm Fairy Tales before going to bed as a little girl. Because of this, I thought that it would be best to add in fairy tales to my own writings. Of all of the women writers in this book, each had a different take on what fairy tales meant to them, whether it be from reading them as a child to being a big influence on their own writings today. Getting several different perspectives on how fairy tales influenced writers that I look up to is fascinating. And it wasnt just fairy tales in general, some writers were influenced by specific fairy tales from Snow White and Rapunzel to 1001 Arabian Nights . One writer, Vivian Gornick, wrote an analysis essay over The Princess and the Pea and how our society nowadays is obsessed with finding the right man, but putting almost no effort into the act of looking and wanting to be swept off of our feet by a knight in shining armor or Prince Charming. Another writer, Linda Gray Sexton, daughter of the late poet Anne Sexton, who wrote an entire poetry collection on fairy tales, remembers what it was like to grow up with her mother, who was always J. Tillman 164 reciting fairy tales as well as what it means for her as a writer trying to define herself as a different person from her mother even though they write about similar topics. With these different interpretations of fairy tales, writing my own story with fairy tale motifs is going to be a unique experience as well as one that isnt so uncommon, but each retelling of each fairy tale is individual. While the story Scars ended up not using the fairy tale motifs I had done the research for, it still helped while writing and editing and going through different phases of editing and versions of the story. J. Tillman 165 Burroway, Janet, Elizabeth StuckeyFrench, and Ned StuckeyFrench. Writing Fiction: A Guide to Narrative Craft . Boston: Longman, 2011. Print. Within this most recent edition of Janet Burroway's craft book, the author lays out many different ideas about how to write narratively, but also how to think about how things work within the English language and its craft. English can be difficult to be in control of when it comes to writing, especially for beginners or nonnative speakers, but it can also be a wonderful skill to have when writing becomes a more natural thing for people to use and understand. Characters can be developed in the English language to become unique and compelling figures who can can change over the course of the story or novel, whichever is being written at the time. For short stories, Burroway says it's a bit more difficult to express lots of change in a short amount of time, but it is not impossible. That is the best advice the author can give me at this point in time, since my writing style is more typical of that from a novel, which I describe details that may seem unnecessary in a short story, but are almost always essential to a novel, from the daily lives of a character before a change, as well as the usual banter of conversations that happen over the course of any day, no matter the situation. Novels seem to be pushed forward by dialogue, which is not necessarily a bad thing, as it allows the readers to further understand the characters and connect with them on a more personal level and create a bond between reality and fiction. The author has laid down several tips for slimming down the text and word count for short stories as well as how to flesh short stories out to make them into longer stories J. Tillman 166 or even a novel, which will definitely come in handy as I continue to work on these stories for my honors project as well as any future writings I do after graduation. J. Tillman 167 Campbell, Bonnie Jo. Mothers, Tell Your Daughters . Brooklyn, NY: Maribeth Batcha, 2015, Print. Besides from loving this collection of short stories for their narrative voice and characters, the relationships is that I seemed to pick up on most from this collection. As the newest collection of published short stories by Bonnie Jo Campbell, many of the stories relate around a main female character interacting with others around her. Sometimes the character of the story is interacting with a boyfriend, who is not the greatest, a brother or other sibling, or a mother. In the title story, the main character is an elderly mother, who has lost the ability to speak to her daughter, and telling her all the stories she wants to tell her but cannot because she is slowly losing her mind. This mother explains that her husband, her daughters father, was not always the best, but they did with what they had and how they continued to survive long after he had left the family picture. This story alone is incredible for understanding how mothers interact with their daughters, and sheds light on how my own mother and I interact and how the mother in my short story collection should interact with her children, and how each of them will have a different relationship with each other, like people do in real life. There is also the interaction that the characters have in this collection of short stories I read. The relationships seemed genuine, not something contrived inside someone elses head. This type of relationship I have struggled to create in my own writing, but by seeing how someone else has created these relationships, I am able to take my own twist on the relationships and make them my own and interesting characters with real centers J. Tillman 168 of conflict and internal struggle that make characters whole instead of just words on a page. That is what I strive for in my own writing. J. Tillman 169 Daz, Junot. This is How You Lose Her. New York: Riverhead, 2012. Print This book has quickly become one of my favorites that I have read for this project. I had read one story out of another book before hand for my Fiction Workshop class, but to read Mr. Dazs newest collection of stories was a great privilege and I was excited that it could be worked into this project. In this collection, most of the stories might come across as similar or the same with different character names. And for some of the stories, like Nilda and The Sun, the Moon, and the Stars, I can see why critics have said that about this collection. In Nilda, for example, the story is about a boy who says he is in love with this girl, Nilda. He wants his whole life to revolve around this girl, who is the high school slut, and how he would treat her right and not act like all of the other guys who just want to sleep with her and brag that they did so. But, the narrator ends up sleeping with her and finds nothing appealing about her, and then turns around and brags that he slept with her and that she wasnt anything special, a waste of his time. That is cruel, but that is the life of a high schooler. There were students in my own high school who had the same nicknames and people said the same things about them. Looking back, it is horrible, but I laughed at them because I was better than the girls who only slept around to gain a name for themselves, such as Nilda in the story. The story did not seem to stick out, at first, to me. It was just another story that I read for this project and I almost skimmed over it because I had so many more books to read and there were other, better, stories in this collection I wanted to read and was excited to read (The Cheaters Guide to Love for example). But the end of Nilda J. Tillman 170 stabbed me in the stomach. It is years in the future and the narrator sees Nilda at the laundromat, children hanging off of her. The narrator comes to an epiphany, one that I was not expecting from the character. The narrator wonders what would have happened if he had not said those things about Nilda to his classmates and if they could have had a better life than the ones they were currently living. On the flip side, he wonders if he had stayed with Nilda, would they still have ended up like this, in a laundromat, children running everywhere, and no money because they chose to raise a family instead of getting out of their rundown town and making a new life for themselves. This sort of conflict is one that is incredible for me and why I will continue to read Junot Daz long after this project is over. That punch in the stomach at the end is a feeling that I love to feel when I am reading a story and one that I want to be able to write and make my own readers feel. I know how it was done in this story and I will try my hardest to add it into my writing, because that is an important feeling to writing that makes stories stand out in readers minds. J. Tillman 171 Francke, Linda Bird. Growing Up Divorced . New York: Linden/Simon & Schuster, 1983. Print. This novel seemed to be more of a psychology book meant to be read by parents than a story to be told. That does not make it a bad thing, it actually helped immensely with the stories I wrote. Since it did have the psychological background for understand divorce and how children in the late 1970s to the early 1980s grew up interpreting their parents divorce and how that can change with age as either the child grows older as the divorce evolves, or the child is older when the divorce takes place. Because of these different reactions, I understood how my own characters would evolve as well as understanding what I myself went through almost 12 years ago with my own parents divorce that inspired this collection. With this book, it was easy to see how things transcribed from one year to the next as well as where things can go differently from me and my characters. These stories are not supposed to be memoirs for myself, but stories about characters who have gone through an experience I have myself, and how things can go differently based on each individual in the story or household. Seeing these changes that people can go through in shared experience is helpful for how to structure my characters away from myself and my family members who some of the characters are based on so that I had an idea of where I wanted them to go in the story itself. With the help of this book, I can now see where my characters are going in their future developments of the stories and how to make the changes seem real and understandable for the character progression as well as for the readers and myself when I am writing the story. J. Tillman 172 List, Julie Autumn. The Day the Loving Stopped: A Daughters View of Her Parents Divorce. New York: Seaview, 1980. Print. Within this nonfiction story, a lot of details are described so readers can fully understand what is going on in the situation. Since this is a first hand account of what the author remembers happening to her and her family after her parents divorce, it was eye opening to read what others have gone through that was either similar or different from me based on who we are as people as well as the time difference. The authors parents got divorced in the 1970s, when noexcuse divorce became legal across the United States meaning that there didnt need to be proof of a bad relationship or cheating to get a divorce, you could get one because you and your partner wanted one. For me, my parents divorced after the turn of the twentyfirst century, so there were changes in society as well as how situations such as divorce were handled in the household and in court. Even though this book was incredibly helpful as a basis for what I want to do for the future of this project, there was a sort of disconnect to the story. Yes, it is about children and their view on their parents divorce, but that time difference of almost fifty years is a big challenge to overcome. With that time difference, readers cannot quite connect with the narrator. The books starts off with a college prom where families are invited to celebrate with their student before they graduate the next day. For me, the only proms I ever went to were in high school, and I definitely did not want my mother to attend that. Because of this disconnect and lack of literature, I am more motivated to publish these stories and make them as best they can be so that young people can read something modern that makes sense to them without the strange social constructs that J. Tillman 173 might be found in older literature that came out around the time of this book when the noexcuse divorce was becoming popular and divorce was more common. J. Tillman 174 Martone, Michael. Not Normal, Illinois: Peculiar Fictions from the Flyover . Bloomington: Quarry /Indiana UP, 2009. Print. While this book came with high praise and expectations, it was a bit of a let down in the sense of storytelling. The premise of the book is a collection of weird and "out there" stories written by people who grew up or are currently living in the Midwest, such as myself here at the University of Indianapolis. The stories were weird, and weird is never bad. I like weird. But the wrong kind of weirdness, for me, came from either the subject or the craft of the writing. The Midwest is not particularly interesting in my opinion, after living here for the past 22 years, but the authors tried to make it so, which is something I appreciate. Not everything in life can be extraordinary when you live in such a place as the corn fields of Indiana. Some of the situations written came across as normal, like the Boy Scouts in their secret hideout after school, but what the whole story was interested in was pretty strange. The Boy Scouts in this particular story, wanted to be on the lookout for communist missiles that could potentially hit their area of southern Illinois during the early era of the Cold War. That is almost impossible it is not going to happen, but these characters want to be on the lookout, "just in case." While stories like this can be appreciated, it is not really something I can use for my own personal work since my project is based in modern times and deals with current situations that affect half of the American population under the age of 18. This is not to say that this collection of stories was a waste of time. It showed me an extreme other end of how stories can be set in J. Tillman 175 reality, but all of this crazy stuff can occur or that they can be totally out there in the sense of story, but still work wonderfully for craft. J. Tillman 176 Munro, Alice. Dear Life . New York: Vintage International, 2012. Print. Many say that Alice Munro is one of the best short story writers of the twentieth and twentyfirst centuries. And to be honest, I have to agree with them. Munro takes very small aspects of life and makes them into intricate stories that either come full circle by the conclusion, or they are a series of unorganized flashbacks that make sense by the end of the story that you would have never understood if you tried to make the story linear. This technique is what I pulled on heavily for my opening story, titled Welcome to Fallen Crest. With the series of flashbacks, it would be hard to tell the story in linear order because each of the scenes is triggered by something in the present, and the way the human brain recalls memories is not linear. Munro captures this thought process in her stories and makes things absolutely beautiful when she tells them. One story in particular stuck out to me, because it was told from the perspective of a young daughter traveling across the country by train, while her mother is off with someone else and trying to get over her own problems. The perspective jumps between the two narrators seamlessly and tell the story from both sides while also bringing an outside perspective on the characters and their actions with one another as well as those with them on the train. The story does not seem that interesting on the outside, but with the thoughts of the characters being the main drive of the story, readers learn about the characters that no one else would know, not even the other characters in the story, all while they are on a train to get somewhere else. Since I have finished this collection, it has opened my eyes to a whole style of writing that I would not have known about and could use for my writing. Because of this, J. Tillman 177 my writing has improved and my knowledge of writing has expanded along with the different ways of telling a story. J. Tillman 178 OConnor, Flannery, and Frederick Asals. A Good Man is Hard to Find. New Brunswick: Rutgers UP, 1993. Print. Flannery OConnor has always been one of my favorite short story authors for her quirkiness and spontaneity with how the story unfolds. Most situations start off as normal, like a family going on vacation in A Good Man is Hard to Find or a mother and daughter starting their day on the farm in Good Country People. All is well, the descriptions are funny and entertaining, making a normal day seem a little bit more interesting than the last. Then, something strange happens. A serial killer kills the family going on vacation and a supposed bible seller steals the daughters fake leg because he thought it would be interesting to add to his collection. The events are incredibly random and almost seem out of place, but they work in the context of the story. The twist comes at the right point where the reader might think that nothing out of the ordinary is going to happen, but then the sudden change has readers attention and continued interest in the story. For my project, this seems like an interesting approach, but might not work as well in my own stories for this collection as some other stories that might develop in the future. There are not serial killers or creepy bible sellers who come to disturb the family I am writing about. But the event or twist does not have to be that. Since the serial killers and the bible seller are hilarious, they leave the reader laughing at the end, even though a family is killed and a girl loses her wooden leg. For my own benefit, it would not be something as hilarious or absurd, but something just as drastic to hook the readers into the story again and have them hold their breath to see how everything turns out. That J. Tillman 179 kind of writing is one that I want to use in my own stories and hope to execute well for all of my readers as well as myself as an author. J. Tillman 180 Russell, Karen. Vampires in the Lemon Grove: Stories . New York: Alfred A. Knopf, 2013. Print. In this collection of stories, craft is everything. The author uses craft to her advantage and creates compelling stories based on craft of the English language rather than the characters or the plot. In the title story "Vampires in the Lemon Grove," the characters are not incredibly interesting, but with the author's use of words and craft, the story reaches a new level of characterization that allows the reader to understand who each character is and the world that they live in without the words on the page directly telling the readers the motives and ideas each character has. The main characters are vampires, but readers understand that they are vampires before they are physically described as one. That level of description and understanding is one that can be achieved through reading several stories like Vampires in the Lemon Grove and other stories in general, while writing and rewriting your own words on the page. It takes practice, and through this practice, the words and stories are beautifully done and keep the reader hooked and continuing to read. There is an underlying layer of depth to each story in this collection it is never explicitly said but understood. This is what I want my writing to be like. Words are precious things that need to be thought about carefully and this collection of stories shows this perfectly. Not only does the collection tell wonderful stories that are created in the reader's mind, but it also shows me, as a writer, exactly how words have an impact on readers in profound and wonderful ways. J. Tillman 181 Saunders, George. Tenth of December: Stories . Random House: New York. 2013. Print. George Saunders is a short story author many writers strive to be one day, myself included. The writing style is unique, compelling, interesting, and easy to become enraptured in. It has been a long while since a short story caught my attention and kept it for a long period of time without interruption. It is a state referred to as the vivid and continuous dream, a term coined by James Gardner when he spoke about the narrative, structure, and plot working together as one to engage the reader for, potentially, forever. One such story in this collection was titled Escape from Spiderhead. While the story did not make sense at the beginning it was an experimental facility that tested new serums and medicine on convicts to help benefit society the character pushed the plot forward. This was his story, after all, and he would tell us what needed to be said. The further into the story I got, the more I wanted it to keep going. I did not want it to end, and when it did, I sat in silence and stared off into space because something inside me was affected by how the story had turned out. It was not something I expected, but when I went back and read it again, it was the only possible ending. The structure of the story is incredibly well done and I want my own readers to experience a story like this one, but with my own characters and plot line. I want to be able to pull readers into the story, and with the help of George Saunders, I have an example of how that idea could work for me. While I will not be writing about scientists performing questionable tasks on convicts, telling the story of children of divorce from different perspectives can be as engaging with readers of Escape from Spiderhead. J. Tillman 182 Stern, Jerome. Making Shapely Fiction . New York: W. W. Norton & Company. 1991. Print. One of the things I fall victim to when I write is using the same style of writing and story structure, which does not add variance to the stories and makes them seem similar to one another rather than their own unique stories as they should be in a collection of interconnected short stories like this. Professor McKelvey recommended this book for different structures for my stories to make the stories more interesting and not so similar to each other, and also open me up to different ways of writing that can be used beyond this project, something that is incredibly important for writers to use and express in their writing if they want to be successful. Of the 16 shapes that can be used for fiction, I looked over ten of them that could possibly be used for the five stories I had written for this honors collection. Several stories had multiple potential shapes and many stories overlapped with one another in potential structure, making the options greater and more interesting when it came to writing the stories themselves. One of my favorite shapes of fiction is called Bear at the Door, that starts with writing a story where there is a problem that is significant and pressing, such as a large bear at the door of a house trying to get in. Anything can happen in this structure, but the most important thing is that the character has to act, and they have to act now. They are not being acted upon, such as Visitation shape mentioned for another story shape. The characters act and their actions are what drives the story forward. The tension in the story comes from the battle between the challenge and the J. Tillman 183 characters need to face the problem because if the character does not react, then the bear is coming into the house and doing whatever it wants to do. And the characters do not have to act logically. The main character cant pick up the knife. He puts a Mozart symphony on the stereo. The puzzled bear eats the record. Life is suggestive, not tidy. Fiction can take any shape it wants and collections of stories are successful as long as each story has a different shape, something this book has shown me and I have used in this project. J. Tillman 184 Watkins, Claire Vaye. Battleborn . New York: Riverhead, 2012. Print. Unlike previous book I have read for this project, this collection of stories is very character based and character driven the opposite of the stories in Karen Russells Vampires In the Lemon Grove , which are very craft based and driven. That is not a problem for Claire Vaye Watkins and her collection of stories since the characters are well put together, thought out, thorough, and compelling. This, combined with a simple narrative, makes the stories compelling, touching, and engaging for the readers that seemed to be lacking in other collections that were more craft based. I found myself crying over the story of a prostitute, something I never thought would happen, and not in a derogatory way the thought had never crossed my mind to either read or write a story on that topic. The story is beautifully done, not because of the "sad life" this prostitute lived, as many people would assume because of her occupation, but that she opened up to another character when she said she would not, and then got stabbed in the back emotionally, that is what made me cry. That is what I need to use in my own writing, the raw emotion that hits hard and can move people into thinking about something they never would have taken a second thought at. My characters must be fleshed out and compelling enough to make readers feel for these fictional beings, but also show that characters are important, not only because they drive the story forward, but because they have human emotion and can seem like real people who are experiencing real feelings in real situations. That is what I learned from this collection, and what I look forward to using in my own writing the most.  ...

... Utilizing Program Development to Address Industry Trends: Thrive, a Successful Care Transitions Program Haley A. Brown May, 2018 A capstone project submitted in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree from the University of Indianapolis, School of Occupational Therapy. Under the direction of the faculty capstone advisor: James McPherson, PhD, OTR Running Head: THRIVE SUCCESSFUL CARE TRANSTIONS PROGRAM A Capstone Project Entitled Utilizing Program Development to Address Industry Trends: Thrive, a Successful Care Transitions Program Submitted to the School of Occupational Therapy at University of Indianapolis in partial fulfillment for the requirements of the Doctor of Occupational Therapy degree. By Haley A. Brown Occupational Therapy Student Approved by: Faculty Capstone Advisor Date Doctoral Capstone Coordinator Date Accepted on this date by the Chair of the School of Occupational Therapy: Chair, School of Occupational Therapy Date 1 THRIVE 2 Abstract This doctoral capstone experience (DCE) sought to expose a DCE student to rehabilitation administration and management at the corporate level at Healthcare Therapy Services, Inc. (HTS), a contract therapy provider in the Midwest. The student was exposed to various aspects of the corporate rehabilitation industry including administration/management, corporate compliance, marketing and business development, program development, and operations. The primary project for this DCE was development of an interdisciplinary successful care transitions program known as HTS Thrive: Successful Care Transitions Program. The program was chosen as the chief project in response to recent insurance and industry regulations incentivizing valuebased care and transitions to the next level of care as soon as necessary supports can be obtained, and additionally in response to rehabilitation in skilled nursing facilities being highly scrutinized for the misuse of Medicare dollars in the form of unnecessary long lengths of stay and excessive Ultra-high Resource Utilization Group (RUG) utilization. The doctoral student, in collaboration with corporate executives, therapists, and other relevant healthcare experts developed an interdisciplinary successful care transitions program to be utilized in HTS-partnered facilities. The outcome of the DCE is a comprehensive interdisciplinary program that will allow HTSpartnered facilities to adhere to recent industry and insurance regulation trends while providing patients with quality care and a complete discharge process to promote a successful care transition to the next level of care. THRIVE 3 HTS Thrive: Successful Care Transitions Program Background/Literature Review Aging Population According to the U.S. Census Bureau (Ortman, J., Velkoff, V., and Hogan, H., 2014), by year 2030 more than 20% of the U.S. population will be aged 65 and older, a projected increase from 13% in 2010, and 9.8% in 1970. The oldest old age group (age 85 and over) is estimated to increase from 5.9 million in 2012 to 8.9 million in 2030 climbing to 18 million by year 2050 (Ortman, J., Velkoff, V., and Hogan, H., 2014). Many consequences will accompany the anticipated increase in the aging population. The expected growth in the older adult population will exponentially increase the need for healthcare for older adults in the United States. Medicare spending is expected to increase annually on average 4.1% per beneficiary from 2016-2025 compared to 1.6% per beneficiary from 2010-2015 (Centers for Medicare and Medicaid, 2017) Medicare Reform With these projections, the pressure to reduce Medicare spending is high and the Centers for Medicare & Medicaid Services (CMS) has consistently implemented programming to increase quality of care without increasing spending and in some cases while reducing spending over the past several years. Healthcare corporations are working hard to comply with CMS regulations in order to provide excellent care while sustaining revenues. Among these, post-acute care facilities such as skilled nursing facilities experience the burden of new regulations dually, as these facilities must comply with CMS regulations while also attempting to appeal to hospitals and potential clients for referrals. Recent CMS legislation affecting these facilities includes the Improving Medicare Post-Acute Care Transformation (IMPACT) act of 2014, which requires all post-acute care settings to report standardized patient assessment data by means of the SNF THRIVE 4 Quality Reporting Program (RTI International, 2017). Measures reported (current and to be implemented in FY 2020) include skin integrity, falls, functional, change in self-care, change in mobility, discharge self-care score, discharge mobility score, potentially preventable 30-day readmissions, discharge to community, and Medicare spending per beneficiary (RTI International, 2017). Post-acute care facilities face a 2% penalty for failing to report this data. Additionally, the SNF Value-Based Purchasing program as required by the 2014 Protecting Access to Medicare Act (PAMA) will withhold 2% of all SNF Medicare payments beginning October 1, 2018 and will provide incentive payments from 50-70% of the funds from this pool for facilities ranking highest on performance measures (SNF Value-Based Purchasing, 2017). Incentive payments will be based upon the 30-day All Cause Readmission Measure (SNFRM) which will transition to the SNF Potentially Preventable 30-day Readmission (SNFPPR) as soon as practicable (SNF Value-Based Purchasing, 2017). Similarly, hospitals are also required to participate in the Hospital Value-based Purchasing Program, which provides incentive payments to hospitals scoring highest on the Clinical Care domain, Patient and Caregiver Centered Experience of Care/Care Coordination domain, Safety domain, and Efficiency and Cost Reduction domain (Efficiency and cost reduction domain, n.d.). Of special interest to post-acute care facilities, the Efficiency and Cost Reduction domain is based on an assessment of payment for services provided to a beneficiary during a spending-per-beneficiary episode that spans from 3 days prior to an inpatient hospital admission through 30 days after discharge (Efficiency and cost reduction domain, n.d.) meaning that costs incurred in post-acute care facilities up to 30 days post hospital discharge will directly affect hospital reimbursements. Hospitals are also scored on readmission rates through the Hospital Readmission Rate Reduction Program (HRRP) initiated in 2012 and are penalized for THRIVE 5 high hospital readmission rates (Boccuti and Casillas, 2017). Hospitals participating in bundled payment programs are also particularly interested in hospital readmission rates as well as length of stay in post-acute care settings, as it has a direct effect on hospital reimbursement. Scrutiny of SNF rehabilitation services. As healthcare facilities and providers struggle to adhere to CMS regulations, they are faced with the task to provide quality care to patients in shorter amounts of time with the threat of potential consequences if unable to do so. For many years, post-acute care facilities have provided patients with care and rehabilitation services for long lengths of time in order for them to return to their prior level of function before discharging to the community. However, trends in steadily increasing Ultra High RUG utilization and patients receiving the minimum allowed minutes for each RUG category in skilled nursing facilities have led to accusations of skilled nursing facilities managing RUG levels for financial gains instead of patient needs (Acumen, 2017). For this reason, rehabilitation services in skilled nursing facilities have been highly scrutinized. Consequently, efforts to reduce this type of abuse of the system are being enacted including a proposed potential payment system that would eliminate the RUG system entirely. The Resident Classification System Version 1 (RCS-1) is the proposed payment model for rehabilitation services in skilled nursing facilities (Acumen, 2017). RCS-1 would pay facilities based on resident characteristics rather than volume of services provided. Although the RCS-1 system is intended to be budget neutral, many facilities may still feel the financial impact of this system, and contract rehabilitation providers are uncertain how the new payment system will affect them (Acumen, 2017). With no regulations on the amount of services provided to each patient proposed at this time, it is imperative that rehabilitation providers are able to articulate the value of their services in order to ensure that patients receive the rehabilitation services they desperately need. THRIVE 6 Justification for Student Project The rapidly growing aging population combined with a recent focus on quality care measures and reducing CMS spending in CMS legislation serve as the basis for this doctoral capstone project. As hospitals strive for lower readmission rates and shorter lengths of stay and post-acute care facilities are focused on reducing readmission rates and hoping to appeal to hospitals for referrals with shorter lengths of stay, a focus on successful care transitions is essential for patient success. In order to provide quality care in post-acute care facilities, successful care transitions from the hospital are vital, and additionally, to facilitate successful community reintegration and reduce hospital readmission rates for patients after a post-acute care stay, successful care transitions to the community are essential (Coleman, Parry, Chalmers, & Min , 2006). As our society ages and healthcare costs continue to grow, providers must be willing to shift type of care provided to meet societal needs. Hospitals and post-acute care facilities will no long be able to treat and rehabilitate patients to their prior level of function in the inpatient setting, as this has become too costly and will only continue to do so as the number of older adults requiring services grows. Avenues for reducing inpatient lengths of stays and readmission rates are potential methods to address this need. Among these, completing successful care transitions to the next level of care whether it is to home health services, outpatient services, or only follow-up with a primary care physician will be essential to provide patients with the best care possible in order to facilitate excellent outcomes for our patients, facilities, and society at large. Theoretical Basis This doctoral capstone project is primarily focused on developing advanced knowledge and skills in management and administration in the rehabilitation setting. Throughout the THRIVE 7 experience I have been embedded into the corporate rehabilitation setting including a focus on corporate compliance issues and quality improvement. Developing a new care transitions program for this site will serve as the main project for this experience and will provide an excellent opportunity to develop and showcase my ability to contribute effective healthcare solutions at the corporate level addressing both societal and facility needs. Dynamic Systems Theory. The Dynamic Systems Theory (DNS) will serve as the theoretical basis for this project. DNS is based upon chaos, complexity, and dynamic systems (Royeen, 2011, p. 63). With the unreliable healthcare climate today, it is only fitting that the theoretical framework to guide an effort to find solutions for societal healthcare needs would take into account the dynamic system that is healthcare in the United States. DNS allows consideration of this project to include potential varying outcomes that may become factual depending on the legislative actions that may take place within the next few months. Using DNS as a framework for this project forces consideration of the potential small changes that could undeniably impact the need for and execution of this program in the future. In considering DNS as a frame of reference for management, Royeen (2011) proposes that management in occupational therapy be renamed to facilitation of change (p. 67). I found this very fitting for the project, as it attempts to facilitate change within post-acute care facilities across the Midwest in order to provide patients with the support they need to transition between hospitals, post-acute care facilities, and the community successfully. It is my hope that I am able to facilitate change to provide better outcomes for our patients, facilities, and communities. Screening and Evaluation Screening and evaluation methods took place at the corporate office for Healthcare Therapy Services, Inc. (HTS). HTS provides contract rehabilitation services to over 100 skilled THRIVE 8 nursing facilities, hospitals, and outpatient clinics across the Midwest, primarily serving the older adult population in the skilled nursing facility setting. AOTA (2014) describes organization level occupational therapy services as a valid and important level of practice, claiming that the indirect application of occupational therapy services in administrative roles support and enhance the services provided to clients. The purpose of this doctoral capstone experience is exposure to administration duties and program development at the corporate level within the rehabilitation context. Thus the client for this experience is quite different than in traditional occupational therapy models. In this experience the client is the organization, Healthcare Therapy Services, Inc. To assess the needs of an organization it is important to perform a needs assessment. Sleezer, Russ-Eftt, and Gupta (2014) identify gathering data, data analysis, collaboration, and negotiation as important parts of identifying and addressing gaps in performance. Additionally, Sleezer et al (2014) states that a careful needs assessment builds support for program development with necessary data to substantiate the actions to follow. To gather information about the needs of my client, I immersed myself into the workplace culture, attending meetings, performing interviews, visiting sites, and reviewing pertinent literature (Scaffa & Reitz, 2014). I attended meetings with the owner, CEO, Executive Director of Clinical Services, and Human Resources Director as well as marketing meetings that included skilled nursing facility administrators. This gave me an idea of what is most important to the organization, and how I might become part of the solution for issues they wish to address. Next, semi-structured face-to-face interviews were performed with key informants I had access to, including the Executive Director of Clinical Services, Marketing and Business Development Director, one regional director, and one occupational therapist. After all interviews were completed, the data was analyzed and placed into categories. Additionally, I was able to visit THRIVE 9 several sites with my supervisor to gather more information about the varying needs of the facilities HTS serves and how my project might impact them. Finally, a thorough review of scientific literature concerning recent and upcoming legislative actions impacting the rehabilitation services HTS delivers provided a greater understanding of the current and potential issues at hand. From this process, a variety of needs emerged including the need to appeal to hospitals for referrals, strategies for improving quality indicators that are being tracked by the SNF Value-Based Purchasing Program, Skilled Nursing Facility Quality Reporting Program and Nursing Home Compare, creation of pathways to reduce lengths of stay, and an improved care transitions program. Ultimately, through careful analysis of the data collected and literature reviewed, in collaboration with my site supervisor (the Executive Director of Clinical Services) it was determined that a successful care transitions program would be the best fit for the needs of the organization. Current literature also suggests that care transitions interventions may lead to better outcomes (Kind et al, 2012; Carnahan e al, 2017; Rahman e at, 2017). An improved, evidencedbased care transitions program would serve as a way to improve quality outcome measures, appeal to hospitals for referrals and to skilled nursing facilities for new contracts, and attempt to improve quality of care to their clients in the changing healthcare climate. Baseline Measures To prepare for future outcomes evaluation of the program, data was collected from the SNF Value-Based Purchasing Program Quarterly Interim Reports (Medicare Program, 2017). All-cause 30-day readmission rates from a convenience sample of HTS-partnered facilities were obtained for future comparison of objective, measurable outcomes. THRIVE 10 Comparison and Contrast to Other Practice Areas This screening and evaluation could be compared to that of the actual clients HTS occupational therapists serve in post-acute care facilities on a daily basis. When performing evaluations in post-acute rehabilitation and long-term care, occupational therapists are focused on determining the needs of the client through careful administration of standardized tests, completion of an occupational profile, and ultimate determination of the deficits that are currently limiting the clients occupational performance. Similarly, the needs assessment of HTS incorporated a process including semi-structured interviews, review of relevant literature, assessment of the client through site visits, and ultimately synthesizing the data to determine the needs of the client to promote optimal performance. Additionally, in both settings, the data is then used to develop goals and objectives for intervention. Although there are similarities in the screening and evaluation process for these two occupational therapy models, there are also great differences between them. Chiefly, the time and effort put into a post-acute care evaluation versus the screening and evaluation for an organization. An occupational therapy post-acute care evaluation may include review of patient chart, evaluation including administration of standardized assessment and occupational profile, and finally the written evaluation which may take a therapist 1-3 hours to complete. In comparison, the process of screening and evaluation of the needs of an organization can take several weeks or longer to gather the necessary information in order to provide the most fitting services to the client. Additionally, when treating individuals, occupational therapists are most often focused on creating improvement in occupational performance, whereas in considering an organization it may more often be focused on limiting poor outcomes such as reducing the risk of financial penalties, rather than being solely focused on improvement of performance. THRIVE 11 Implementation Phase Healthcare Therapy Services, Inc (HTS) services a large geographic location including over 100 facilities across Indiana, Kentucky, Tennessee, and Michigan. Many of these facilities are privately owned, non-profit organizations. The Centers for Disease Control and Prevention reports that 69.8% of nursing facilities in the United States are for-profit, making the HTS clientele quite different from the norm in the long-term care world (Harris-Kojetin, Sengupta, Park-Lee, et al., 2016). These types of facilities do not possess large corporate management, and consequently must often depend on HTS for education regarding regulations and best practice in long-term care. As discussed previously, recent Centers for Medicare & Medicaid Services (CMS) legislation and initiatives including the IMPACT Act, SNF Quality Reporting Program, and SNF Value-Based Purchasing Program all place great emphasis on quality outcomes, including safe care transitions to the community and 30-day hospital readmissions (RTI International, 2017; SNF Value-Based Purchasing, 2017). Based on the current healthcare climate in the wake of recent CMS legislation, it was decided by the doctoral capstone student and site supervisor that development of a successful care transitions program would be the most beneficial project the student could develop for the organization at this time. The following paragraphs will discuss the process of implementation of the program. Program implementation within HTS poses unique challenges. First, the large geographic area makes implementing various programs and disseminating information problematic. One way HTS has combated this issue is to provide virtual presentations utilizing ZOOM online meeting software. ZOOM combines a slideshow with video conferencing to allow for face-toface meetings miles apart. Recording a ZOOM webinar presentation discussing the program will be the first step in implementing the HTS Thrive: Successful Care Transitions Program. The THRIVE 12 student will provide a virtual presentation via ZOOM explaining the need and purpose for, evidence behind, and implementation guide for the voluntary successful care transitions program provided by HTS. The presentation will be provided first to all HTS regional directors at a lunch and learn presentation. It will be sent to the regional directors a week prior to being sent out to the facilities in order to give the regional directors sufficient time to become familiar with the program and ask necessary questions. This is an important step in the implementation process, as regional directors are available to communicate with facilities more frequently and have a closer relationship with facility administrators than other corporate employees may. Next, the presentation will be presented to all HTS facilities that are appropriate for program utilization. This presentation will also be presented at a lunch and learn meeting for facility administrators. Presenting at a designated time in which viewers must log on to view will create more accountability for administrators to view the presentation. The presentation will be available at a later date to administrators who are unable to view the live presentation. Along with the presentation, facilities will be provided with a written program manual including specific guidelines for each discipline involved and interactive tools for the facility to use in their facility-specific transitions program. Information will also be included concerning reporting program outcomes to HTS for continuous evaluation of the program. This will be discussed further in the next section. After educating regional directors and facility administration, implementation will continue with rehabilitation, nursing, and social services managers. The program includes a large portion to be completed by nursing staff, signifying the need for facility-wide participation for successful implementation. Nursing managers will be provided with the virtual presentation as well as a complete step-by-step guide detailing the type of staff required to carry out the program and the THRIVE 13 specific duties these staff members will provide as part of the HTS Thrive: Successful Care Transitions Program. Additionally, the rehabilitation and social services managers will also receive the virtual presentation and a written step-by-step guide detailing the duties of each rehab discipline and social services representative as part of the safe care transitions program. It will then be the responsibility of the managers to relay information regarding the specific job duties to each staff member involved. This may include requiring staff members to view the provided virtual presentation, reviewing the HTS Thrive: Successful Care Transitions Program manual, and holding a department education meeting about the implementation of the program. Specific training needs will be determined by department managers on a facility-by-facility basis. Creating Buy-In Additionally, it is important to note the unique relationship HTS has with its clients (partnered facilities). HTS provides therapy services within facilities and often provides consultation and occasionally marketing services; however, HTS does not have directive over the facilities it serves. Thus, programming that includes personnel other than those employed by HTS is completely voluntary. Consequently, buy-in from facility administrators and staff is essential for the success of this program. In order for the program to be utilized and given the chance to provide successful outcomes for the facilities and patients served, buy-in from administrators and other staff members must be generated. In addressing this area, the student has been able to develop leadership skills further by carefully considering and planning how to create buy-in from these facilities. To create buy-in the student must be able to successfully and professionally articulate the need for this type of program, the research completed to determine the best actions to promote successful outcomes, and why the student feels she is qualified to develop and oversee the implementation of this program. The development of this project has THRIVE 14 helped to improve the students leadership skills by providing opportunities for high-level conversations regarding real facility and patient issues in the current healthcare climate. It has also forced the student to be very professional in the development of the program, as the student understands the large consequences this program has the potential to provide. Although the large scope of the project has felt overwhelming to the student at times, she is confident that the development of this program has helped her grow as a leader in the profession and in the healthcare industry. Staff Development and Program Outcomes The implementation of this program combines efforts to improve patient outcomes with staff education. Educating staff on current regulations and updates within the healthcare climate, as well as best practice for successful care transitions promotes an understanding of the effect that current legislation is and will continue to have on rehabilitation service provision within the skilled nursing facility setting. The outcome of the program is two-fold. It will provide facilities with strategies to combat poor outcomes, allowing them to be looked upon more favorably by consumers, potential partners, and CMS. Additionally, it will provide staff with education regarding strategies for improving outcomes and patient care, as well as educating them on the current healthcare climate and its effect on rehabilitation service provision in the skilled nursing setting. Discontinuation & Outcome Phase Societal Need The population served by HTS facilities is largely comprised of older adults, many with multiple comorbidities and complex care needs. Evidence suggests that elderly people are particularly vulnerable to issues with discontinuity of care, potentially resulting in adverse THRIVE 15 outcomes (Coleman, 2003). In particular, elderly patients with cognitive deficits often experience repeated hospitalizations and uncoordinated care resultant from reliance on the healthcare system to effectively communicate and transfer care responsibilities to appropriate caregivers (Aase, Laugaland, Dyrstad, & Storm, 2013). The care success for the population served by HTS facilities is largely dependent on healthcare providers ability to maintain continuity of care. This is especially important in the current healthcare climate that incentivizes shorter lengths of stay in inpatient facilities and various transitions to lower levels of care. This DCE project is in response to the needs of the older adult population served by HTS in the context of recent industry trends in response to legislative and regulatory changes. These changes will determine the healthcare services and the amount of services that are provided to CMS patients, as well as the level of reimbursement facilities will receive for the services rendered. As previously discussed, the population in the United States is growing older at an exceptional rate with the number of seniors expected to double by the year 2030 and triple by the year 2050 (Ortman, J., Velkoff, V., and Hogan, H., 2014). This will put great strain on the United States government to support our aging population. Thus, efforts to reduce CMS spending while maintaining and/or improving quality of care are being implemented. These efforts will force service providers to render quality care in shorter amounts of time in order to transition patients to the next level of care at a lower cost to CMS. Thus, providers must learn to successfully transition their patients care to the next level of care providers to maintain continuity of care. This will be essential for successful patient outcomes in the new healthcare climate (Coleman & Boult, 2003). This DCE project aims to meet the needs of HTS facilities in order to provide best care to patients in the context of recent healthcare climate changes. By providing facilities with the tools to combat these issues, this project will be a key component to THRIVE 16 assisting HTS and its facilities to meet the needs of society in the context of a continually aging population and recent healthcare climate changes. Outcomes of the Program As previously described in the implementation phase, the relationship HTS has with its partnered facilities makes implementation and, consequently, measuring outcomes challenging. Due to the voluntary nature of the program, each facility may choose to implement or not implement the program. Additionally, facilities may choose to adapt parts of the program as necessary to meet that unique facility and patient population needs. To drive continuous improvement of the program, an established plan for measuring outcomes is imbedded within the program. The outcome measures for the program are largely focused on improving reported measures required by the SNF Value-Based Purchasing Program and SNF Quality Reporting Program such as SNF 30-Day All Cause Readmission Measures (SNFRM), average Medicare beneficiary spend, discharge to community rates, discharge mobility scores, discharge self-care scores, etc. Of these, the SNFRM is of chief importance, as it will determine the top ranking facilities that will receive the highest incentive payments via the SNF Value-Based Purchasing Program (VBP) beginning October 1, 2018 (SNF Value-Based Purchasing, 2017). Outcome measures for the HTS Thrive: Successful Care Transitions Program include monitoring 30-day hospital readmission rates via patient phone call surveys and SNF Value-Based Purchasing Program Quarterly Reports. Additionally, utility of the program will be evaluated via an HTSadministered facility survey of the program. To measure 30-day hospital readmission rates and the affect the program has on the rates, the facility will monitor 30-day hospital readmission rates via SNF VBP quarterly reports. These reports will give the facility an accurate measure of the facilitys hospital readmission rates that they can compare to their patient-reported rates. THRIVE 17 Quarterly rates should be monitored for one year, as the reports are sent several months after the quarter has ended. Additionally, the student has implemented a patient survey that includes items evaluating the patients use of hospital services since being discharged from the hospital and skilled nursing facility. The patient will be called by an employee from the skilled nursing facility beginning at 30 days post skilled nursing facility discharge to complete the survey. A staff member other than the staff member that completed the patient post-discharge calls (part of the HTS Thrive program) will complete the survey call to reduce survey bias. A non-skilled staff member may complete the survey calls, as this call is meant only to gather information. The information gathered from the survey will be entered into an Excel workbook that the student created, which will allow the facility to document and monitor hospital readmission rates. The Excel workbook also allows for additional items such as education level, condition category, Allen Cognitive Level score, and primary language to be added based on each facilitys unique needs to help identify and address facility-specific issues leading to hospital readmissions. The facility should note that patient reported rates may not be entirely accurate and should be compared to SNF VBP quarterly reports once they are available; however, patient-reported rates will give facilities a look at their readmission rates in real time. Based on the impact on readmission rates and quality of care post implementation, the facility may choose to continue or discontinue implementing the program, make necessary changes to improve the implementation and utility of the program, and/or suggest edits for HTS to develop for the program as a whole. The Excel spreadsheet included in the program will allow the facility to monitor their readmission rates and potentially pinpoint issues that their readmitted patients have in common. Quality improvement should be completed on a facility-by-facility basis, as the needs of each facility may vary and tailoring the program to meet these unique THRIVE 18 needs will allow for best outcomes. Facilities will be advised to evaluate and make necessary changes to the program each quarter. In addition, a facility survey will be sent out bi-annually for the first year of implementation to assess the utility of the program. The survey will include items monitoring the facilitys 30-day readmission rates, the facilitys assessment of the qualitative improvements to care resulting from implementation of the program, as well as the ease of use of the program and potential issues related to the program. The results of the facility surveys will allow HTS to assess the outcomes and usefulness of the program. Based on these results, necessary changes and/or additions, to the existing HTS program may be completed. Additional Doctoral Capstone Experiences In addition to the development of the HTS Thrive: Successful Care Transitions Program, the student also engaged in various other skill developing and educational opportunities. The student participated in weekly corporate compliance meetings with the Proactive Medical Review consultant, all HTS regional directors, the Executive Director of Clinical Services, CEO, Marketing Director, and owner of HTS. The student completed various site visits with the Executive Director of Clinical services; the student was able to sit in on best practice trainings for staff and regional director trainings, attend facility marketing meetings, complete therapist performance observations, and more during the site visits. The student helped facilitate a Virtual Dementia Tour event at an HTS facility and was able to experience the tour at the site. Throughout her time at HTS, the student has been exposed to various professional organizations that HTS is involved in and that impact the rehabilitation world. The student became involved with various organizations in which HTS is a member. The student attended the American College of Health Care Administrators District 3 Midwest Post-Acute Care Leadership Summit THRIVE 19 and completed a seven-hour Alzheimers Disease and Dementia Care Seminar course qualifying her to receive recognition as a Certified Dementia Practitioner. She also attended the Samaritan Alliance Spring Leadership Forum and Proactive Medical Review The New Long-Term Care Survey Process- What to Expect seminar in person and attended The National Association for the Support of Long-Term Care (NASL) virtual committee meetings. Additionally, the student contributed to the site through development of and contribution to the therapist skills competency check-off list and guide that will be used to assess the competency of all therapists at HTS. Evaluation/Outcomes of the Doctoral Capstone Experience Outcomes of the student doctoral capstone experience (DCE) were evaluated based on the goal attainment scale (GAS) developed to assess the students progress towards meeting the goals for this DCE. Goal attainment scaling as first described by Kiresuk and Sherman (1968) involves construction of a personalized goal attainment guide, and later quantifying progress through evaluation using the guide at a set time after the intervention or experience is completed. The goals determined to be most significant to the DCE were converted into a Goal Attainment Scale to be used for the students evaluation at the end of the DCE. The site supervisor monitored the students progress towards the goals by evaluating the advancement at midterm and final. At midterm, the student and site supervisor determined which goals were not yet met, how to work towards meeting these goals, and opportunities the student would still like to participate in prior to leaving the site. At the final evaluation, the site supervisor assessed the students success in meeting the set goals using the GAS created seen in Figure 1. THRIVE 20 Goal #1 Goal Success at end of DCE Somewhat more than expected (+1) Somewhat more than expected (+1) The student spent time with therapists, managers, regional directors, and all members of the corporate office team. The student was also exposed to fiscal and operational aspects of corporate administration. The student developed an interdisciplinary successful care transitions program for the company. The student created a presentation to educate staff on the program and set up a plan for continuous improvement of the program to take place. The student was able to provide accurate and valuable educational material concerning industry and insurance regulations as they relate to the program she developed. This information will be used to educate facility administrators and guide them in best practice related to recent industry trends. The student became familiar with all associations HTS is a part of and was able to attend events put on by the American College of Health Care Administrators, The Samaritan Alliance, and Proactive Medical Review during her DCE. Poor Understanding of Administrators role Unable to identify appropriate area for program development Familiar with corporate consultant role for industry regulations and insurance regulations No direct or indirect involvement in professional associations that HTS is active in - Spend time with 1 levels of administration No exposure to fiscal and business outcomes and corporate relations with both existing and new customers - Spend time with 1-2 levels of administration - Little exposure to fiscal and business outcomes and corporate relations with both existing and new customers - Understand administrators role within HTS - Spend time with several different levels of administration - Assist administrator in completing various duties to better acquaint myself with the role of rehabilitation administrators - Become well-informed Student demonstrates only general knowledge of industry and insurance regulations and is unable to navigate necessary resources - - Identify area for program development but not able to fully implement advances accordingly Understand corporate consultant role for industry regulations and insurance regulations - - Expected (0) Goal #4 Somewhat more than expected (+1) Fair Understanding of Administrators role Somewhat less than expected (1) Goal #3 Somewhat more than expected (+1) - Much less than expected (2) Goal #2 Identify areas for program development and implement advances accordingly, including research and education for best practice - Observe company culture and interview practitioners, managers, admin, etc. to assess the needs of the company. - Develop a program/protocol to address said needs of the Become informed about CMS regulations and reimbursements and managed care and reimbursements Learn to navigate CMS website and other resources for regulations Understand corporate compliance with these regulations Serve as assistant to corporate consultant for industry regulations and insurance regulations, ensuring compliance in all areas. - Become well-informed about CMS regulations and reimbursements and managed care and reimbursements - Learn to navigate CMS website and other resources for regulations Poor understanding of how these associations support HTS and rehabilitation professions in general Not able to attend any events Involvement in professional associations that HTS is active in - - Understand how these associations support HTS and rehabilitation professions in general Not able to attend any events Involvement in professional associations that HTS is active in - Attend events when appropriate - Understand how these associations support HTS and rehabilitation professions in general THRIVE 21 of fiscal and business outcomes and corporate relations with both existing and new customers Excellent Understanding of Administrators role - Somewhat more than expected (+1) Much more than expected (+2) - Spend time with all levels of administration Frequent exposure to fiscal and business outcomes and corporate relations with both existing and new customers Excellent understanding of Administrators role & ability to act as a manger or administrator - Spend time with all levels of administration Ability to collaborate and contribute to conversation on fiscal and business outcomes and corporate relations with both existing and new customers company - Implement program/protocol - Evaluate success of program/develop outcome measure to assess success of programs Identify areas for program development, implement program fully, and educates staff on use of program professionally and successfully - Understand corporate compliance with these regulations Serve as a corporate consultant for industry regulations and insurance regulations AND is able to provide accurate information and guidance to corporation, ensuring compliance in all areas - Develop program that meets needs of company, implement the program effectively, educate staff on the program, make continuous improvement changes to program based on measured outcomes of the program Able to assist in creating necessary content to educate staff on regulations and best practice related to new regulations Serve as a corporate consultant for industry regulations and insurance regulations AND is able to provide accurate information and guidance to corporation, ensuring compliance in all areas - Able to create necessary content individually to educate staff on regulations and best practice related to new regulations Involvement in professional associations that HTS is active in - Understand how these associations support HTS and rehabilitation professions in general Attend at least one event Be an active participant in the event/conference - - Involvement in professional associations that HTS is active in - - - Understand how these associations support HTS and rehabilitation professions in general Attend at least one event Present information at an event/conference Figure 1. Goal Attainment Scale. This figure depicts the stated goals in a Goal Attainment Scale used to determine if the students goals were accomplished and to what extent by the conclusion of the DCE. Success of Goals The student scored a Somewhat more than expected (+1) on the Goal Attainment Scale for each of the four established goals. Based on these scores, the student fulfilled and exceeded the expectations for this DCE. The success of each goal can be seen in Figure 1 and a description of each is found below. Goal 1: Understand administrators role within HTS Objective: Spend time with several different levels of administration Objective: Assist administrator in completing various duties to better acquaint myself with the role of rehabilitation administrators THRIVE 22 Objective: Become well-informed of fiscal and business outcomes and corporate relations with both existing and new customers Success of Goal 1: Somewhat more than expected (+1.) The student spent time with therapists, managers, regional directors, and all members of the corporate office team. The student was also exposed to fiscal and operational aspects of corporate administration. Goal 2: Identify areas for program development and implement advances accordingly, including research and education for best practice Objective: Observe company culture and interview practitioners, managers, admin, etc. to assess the needs of the company. Objective: Develop a program/protocol to address said needs of the company Objective: Implement program/protocol Objective: Evaluate success of program/develop outcome measure to assess success of programs Success of Goal 2: Somewhat more than expected (+1.) The student developed an interdisciplinary successful care transitions program for the company. The student created a presentation to educate staff on the program and set up a plan for continuous improvement of the program to take place. Goal 3: Serve as assistant to corporate consultant for industry regulations and insurance regulations, ensuring compliance in all areas. Objective: Become well-informed about CMS regulations and reimbursements and managed care and reimbursements Objective: Learn to navigate CMS website and other resources for regulations THRIVE 23 Objective: Understand corporate compliance with these regulations Success of Goal 3: Somewhat more than expected (+1). The student was able to provide accurate and valuable educational material concerning industry and insurance regulations as they relate to the program she developed. This information will be used to educate facility administrators and guide them in best practice related to recent industry trends. Goal 4: Involvement in professional associations that HTS is active in Objective: Attend events when appropriate Objective: Understand how these associations support HTS and rehabilitation professions in general Success of Goal 4: Somewhat more than expected (+1). The student became familiar with all associations HTS is a part of and was able to attend events put on by the American College of Health Care Administrators, The Samaritan Alliance, and Proactive Medical Review during her DCE. Overall Learning Throughout the doctoral capstone experience, the student was able to engage in various opportunities related to administration and management in rehabilitation at the corporate level, culminating in the overall learning experience. The student was exposed to several facets of the corporate rehabilitation industry throughout the experience including administration management duties concerning program development, corporate compliance, marketing and business development, and operations. Program development THRIVE 24 Program development comprised a large portion of this doctoral capstone experience. The student researched, collaborated on, and ultimately developed an interdisciplinary successful care transitions program for HTS. Through this experience, the student became knowledgeable about current industry and insurance regulations that guide current practice, effective strategies for increasing continuity of care after discharge from skilled nursing facilities, and the care transition needs of HTS clients and patients served. The student conversed with various HTS employees to gain an understanding of the current practices and needs as well as to gain feedback on the program as it was being developed. The student learned to express her ideas and work verbally and in writing in a professional and effective manner, which allowed her to gain the respect of her peers in the industry and will serve her well in future jobs and opportunities. The student also improved her professional presentation skills through a virtual presentation for all facilities receiving the program she had developed. The program was presented in such as way as to communicate the benefit of utilizing the program supported by evidenced-based research, and the potential for quality measure improvements in both quantitative and qualitative outcomes. Corporate Compliance Corporate compliance is of utmost importance at HTS, as the company strives to be the performance proven and acknowledged industry leader in therapeutic services, providing effective solutions and ethical practices (Healthcare Therapy Services, Inc., n.d.). Throughout the DCE, the student was exposed to several issues and meetings concerning corporate compliance. The student sat in on weekly compliance meetings with regional directors and assisted with occasional compliance issues as they arose. The student attended a Proactive Medical Review annual quality assurance site visit with a Proactive consultant, where she was able to observe THRIVE 25 first-hand the process of service quality audits at HTS. Additionally, the student assisted with therapist performance observations checking for best practice, accurate billing, and effective documentation. These experiences exposed the student to common compliance issues in the skilled nursing facility setting. As a result, the student now has an enhanced understanding of how care should be provided and documented to assure services are completed in a skilled and justified manner. In addition, the student was exposed to the ill consequences that poor compliance may lead to, further increasing her understanding of and appreciation for ethical provision of services in the skilled nursing setting. Marketing and Business Development This DCE has expanded the students understanding of the role marketing and business development plays in healthcare. The student had the opportunity to work with the marketing/business development team on her successful care transitions program and witness various other marketing and business development efforts throughout the experience. Through the collaboration, the student gained an understanding of how the program might affect the experience of patients as well as the facilities from a marketing and business development perspective. It was also brought to the students attention that the program may be used as a marketing effort to gain new partnered facilities, and thus edits were made to the program to make it more patient friendly and appealing to patients as well as potential partners. The student was also able to witness the marketing director/head of business development present the company to several potential partners. Prior to this experience, the student had a very narrow view of the role of marketing and business development in healthcare, believing that most of the work consisted of social media posts and brochures; however, this DCE has opened her eyes and allowed her to see the vast role and impact that marketing and business development plays in the THRIVE 26 healthcare world, largely driving the opportunities for service provision. Through this exposure, the student has gained a greater appreciation for the entire healthcare team, including the supportive healthcare services such as marketing and business development that help make healthcare possible. Operations Throughout the DCE experience, the student was exposed to the operational side of the corporate rehabilitation administration world including financial concerns and how they affect rehabilitation service provision. Although no extensive knowledge of operational and financial management was gained, the student now has an overall greater understanding of operational management in this setting. Patient care should always of utmost importance in healthcare provision; however, healthcare providers must be aware of the financial business that healthcare has become. This aspect of healthcare will to continue driving profitable margins for the companies and their employees; however, it may come with changes unwelcomed by employees. The student feels the knowledge and understanding she has gained concerning operations in healthcare will help her be a well-informed and flexible practitioner and potentially, manager one day. Conclusion Through this DCE, the student was exposed to rehabilitation administration and management at the corporate level. The student is grateful for this experience, as she understands that few practitioners have an opportunity to witness this side of the rehabilitation industry. The exposure and resultant knowledge and understanding of this industry gained are truly invaluable. The student feels that this experience will aid her in practicing as an effective and informed therapist and potential manager for many years to come. THRIVE 27 References Acumen (2017). Skilled Nursing Facilities Payment Models Research Technical Report. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/SNFPPS/Downloads/SNF_Payment_Models_Research_Technical_Report2017 04.pdf American Occupational Therapy Association (2014) Occupational therapy practice framework: Domain and process (3rd ed ) American Journal of Occupational Therapy, 68(Suppl 1), S1 S48 http://dx doi org/10 5014/ajot 2014 682006 Aase, K., Laugaland, K. A., Dyrstad, D. N., & Storm, M. (2013). Quality and safety in transitional care of the elderly: the study protocol of a case study research design (phase 1). British Medical Journal Open, 3(8). doi:10.1136/bmjopen-2013-003506 Boccuti, C., and Casillas, G. (2017, March). Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program. The Henry J. Kaiser Family Foundation. Retrieved from http://files.kff.org/attachment/Issue-Brief-Fewer-Hospital-U-turns-TheMedicare-Hospital-Readmission-Reduction-Program. Carnahan, J. L., Slaven, J. E., Callahan, C. M., Tu, W., & Torke, A. M. (2017). Transitions from skilled nursing facility to home: the relationship of early outpatient care to hospital readmission. Journal of the American Medical Directors Association, 18(10), 853-859. doi:10.1016/j.jamda.2017.05.007 Centers for Medicare and Medicaid Services. (2017, February 15). 2016-2025 Projections of National Health Expenditures Data Released. Retrieved from THRIVE 28 https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Pressreleases-items/2017-02-15-2.html Coleman, E. A. (2003). Falling through the cracks: challenges and opportunities for improving transitional care for persons with continuous complex care needs. Journal of the American Geriatrics Society, 51(4), 549-555. doi:10.1046/j.1532-5415.2003.51185.x Coleman, E. A., & Boult, C. (2003). Improving the quality of transitional care for persons with complex care needs. Journal of the American Geriatrics Society, 51(4), 556-557. doi:10.1046/j.1532-5415.2003.51186.x Coleman, E. A., Parry, C., Chalmers, S., & Min, S. (2006). The Care Transitions Intervention. Archives of Internal Medicine, 166(17), 1822. doi:10.1001/archinte.166.17.1822 Efficiency and cost reduction domain. (n.d.) Retrieved January 23, 2014 from https://www.medicare.gov/HospitalCompare/Data/efficiency-cost-reduction-domain.html Harris-Kojetin, L., Sengupta, M., & Park-Lee, E. (2016). Long-term care providers and services users in the United States: Data from the National Study of Long-Term Care Providers, 20132014. National Center for Health Statistics. Vital Health Stat 3(38). Healthcare Therapy Services, Inc. (n.d.) About. Retrieved from https://www.htstherapy.com/about/. Kiresuk, T., & Sherman, R. (1968). Goal attainment scaling: A general method of evaluating comprehensive mental health programs. Community Mental Health Journal, 4,443-453. Kind, A. H., Jensen, L., Barczi, S., Bridges, A., Kordahl, R., Smith, M. A., & Asthana, S. (2012). Low-cost transitional care with nurse managers making mostly phone contact with THRIVE 29 patients cut rehospitalization at a VA hospital. Health Affairs (Project Hope), 31(12), 2659-2668. doi:10.1377/hlthaff.2012.0366 Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities for FY 2018, SNF Value-Based Purchasing Program, SNF Quality Reporting Program, Survey Team Composition, and Correction of the Performance Period for the NHSN HCP Influenza Vaccination Immunization Reporting Measure in the ESRD QIP for PY 2020. 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