EARLY INTERVENTION SERVICES USING A PRIMARY SERVICE PROVIDER MODEL

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1 EARLY INTERVENTION SERVICES USING A PRIMARY SERVICE PROVIDER MODEL Three years ago the Fraser Valley Child Development Centre (FVCDC) embarked on a journey that involved research and evaluation of best practices in early intervention services for infants, toddlers and preschool age children with special needs. FVCDC provides services in the Upper Fraser Valley encompassing communities on both sides of the Fraser River from Abbotsford to Boston Bar. The area has a population of over 250,000 including 16,000 children under the age of five. The geographic land area is 13,361 square kilometers all though most of the population is densely located on either side of the Fraser River. In the two largest communities we serve, Abbotsford and Chilliwack FVCDC have Infant Development Consultants, Supported Child Development Consultants, Early Intervention Therapists, Family Support Workers and Key Workers housed together. In Abbotsford the Ministry of Children and Family Development - Early Childhood Mental Health team is co-located with us. FVCDC undertook the evaluation of it s service delivery model as it was faced with rising numbers of children and families requiring services with a finite amount of resources. Families reported to us that our system of service delivery was confusing and frustrating. Often professionals arrived at their home only to tell them their child would benefit from services but they would have to wait anywhere from 6 to 18 months. A few children received numerous services and large number of children received little or no service. Families that did receive services were often inundated with professionals who sometimes gave mixed messages. There appeared to be little coordination and a lack of communication with families regarding the delivery of services. There was also the belief that if we only had more money (equaling more staff) we could serve more children. It was evident that even if there was more money there were not sufficient numbers of pediatric therapists to meet the demand for services in the province of BC, or indeed Canada. Even with an influx of funds it would be years before universities could increase capacity and graduate sufficient therapists. The management team concluded that there had to be a better way to organize services and make better use of the existing resources. Having identified the inherent flaws and concluding our model of service was actually preventing our therapists and consultants from effectively being able to provide service to children and families in a timely manner, a small committee of three was appointed to research a new model of service delivery. This committee consisted of a social worker, occupational therapist and a psychologist. We would later expand the committee to

2 include the complete management team representing department heads for each discipline. The development process involved exploring other models of service in Canada and United States, reviewing published literature by leaders in the field such as Guralnick, McWilliams and Dunst. A significant amount of time was spent exploring discipline and best practice beliefs and ideas resulting in a common vision within the organization. Important practice principles identified include: Families know their children best. Families and caregivers play the most important role in a children s life and the daily interactions between families and children have the greatest impact on child progress. Children learn best in natural environments. Families prefer to have one consistent person working with them over time. Services should be provided in the least intrusive manner, which includes being cognizant of the number of professionals involved with a family at any one time. Commitment to a strength based approach when working with children and families. Respecting and sharing of individual skills between team member and within the organization. We found that organizations that used multidisciplinary teams in a consultative model were most able to meet the needs of the child and their family in the timeliest manner. The use of a primary service provider responsible for coordinating the services of the other team members enables those other team members to use their more limited time resources in the most effective manner. The dismantling of services silos that existed within the organization would result in a more efficient service delivery model. In response to what we learned we developed the goal of: One door, one model, one key contact over time, one plan with access to an array of services and expertise in a timely manner. Next task was to share the vision with the staff. Initially the concept was greeted with the usual skepticism that often accompanies proposals of change. There were concerns regarding transfer of function, children s true needs being missed, and overlap of discipline boundaries. A major paradigm shift on the part of the more experienced staff was required, moving from a believe that they needed to individually shoulder the responsibility for each child to one of trusting that through involvement of other disciplines more could be accomplished. The staff already worked together as geographical teams but more needed to be learned before the teams could meet the vision. Staff needed to bond and develop trust together as teams.

3 To implement the new service delivery model we needed to enhance the work of our teams. Geographical teams already existed but in most instances staff sat in close proximity to their own disciplines and worked in separate offices from other staff. Staff tended to relate first to the discipline teams and secondly to their geographic team. There was a conscious effort on the part of management to afford opportunities for staff to relate more as cross and multidisciplinary teams. Efforts involved physically moving staff into common areas and out of more isolating locations within the offices. OT, PT, SLP, Family Services, Infant Development and Supported Child Development Consultants were relocated to be spaces in close proximity to their team members regardless of professional discipline. This afforded more opportunities to consult and develop relationships in an informal manner. A consultant was contracted to work with individual teams to develop team culture, team charters and models for resolving conflict. Teams were given a full day team retreat. One half of the day was spent with the consultant and the second half of the day was spent in a team building activity of the team s choosing. Team days have become a yearly practice with the goal of engaging staff in the ongoing evaluation of services and development of new ideas coupled with building their team skills. The goal was to create the conditions for the professionals in the organization to work together in the most effective and efficient way in order to achieve the best outcomes for the families and children served. The management team, also a multidisciplinary team, modeled the expectations by also having a team day, developed a team charter and explored models of conflict resolution. The management team also spent time reviewing literature on team development and models of change in preparation to support staff through the process. Without the shift to collocated multidisciplinary teams and the efforts made to develop team culture the ultimate goal to move to a new model of service would not have been as successful or as smooth a transition. Two of the resources, amongst others, that we used in our work around team development were: Working Together Enhancing Multidisciplinary Primary Care in BC (A policy Paper by BC s Physicians October 2005) Primary Health Care and Physical Therapists-Moving the Profession s Agenda Forward. Common to both papers were a set of characteristics or key elements to effective team work. The team has a clear and common purpose. The team must possess synergy and works by pooling knowledge, skills and resources and all members share responsibility for outcomes. Clear understanding of role release, role sharing and those activities that are the sole responsibility of a discipline. (know what you don t know)

4 Everyone has a clear understanding of their roles and responsibilities within team processes. Effectiveness of the team is related to its capability to carry out the work and manage itself as an independent group of people. The team demonstrates participation in good group relations. Professionals from various backgrounds entering into a team illustrate the importance of having confidence in each other; rely on each other; trust each other; and the inherent risks of entering into such a relationship Important to the success of the teams also included: Clear procedures Appropriate administrative support. Technology including a web based electronic client records system. Resources to get the job done. Professional development opportunities. Continued team development opportunities. Along with team development there needed to be a greater recognition that families have the greatest impact on the outcomes of their child s growth and development. We achieve more by sharing our skills and knowledge with those caring for the child and helping them find ways to incorporate strategies into everyday activities in natural environments. All services are directed towards assisting the families/caregivers to provide the intervention. Service and intervention are not the same thing. Service is what the professionals provide, whereas the majority of the intervention the child receives is from his/her caregivers. R.A. McWilliam, PhD. (2003). Intervention happens between visits. Families sometimes feel that more is better but too many visits from a professional may send a message of disempowerment. A goal of Early Intervention should be to support families while enhancing their child s development. Our goal is to help families/caregivers become the interventionist for their child. The FVCDC changed how we introduced and described our services to families including the importance of their role and emphasized they would have access to a variety of professionals though their service coordinator (primary service provider). Using the service coordinator model has allowed the FVCDC to make the best use of limited and available resources. The service coordinator uses a holistic approach to initially meet the family, hear their story and screen the child s development. They then meet with their team to determine the best intervention for the family based on the family s priorities. The service coordinator guides the family through the areas of support and intervention and assists with external agency referrals and resources. Whenever possible the service coordinator would be consistent so each family in essence has their go to person.

5 The approach to service delivery in which one primary direct service provider works with the family is consistently recommended as the preferred method for the provision of early intervention services (Hanson and Bruder, 2001 et all, Guralnick, 1998). McWilliam and Strain (1993) identified indicators of quality services which include delivery of these services in the least restrictive and natural environment using a transdisciplinary approach. Services must be individualized for the child, family and development needs as well as being family-centered and responsive to family priorities. Services also need to be guided by empirical results, family and professional values. One professional (usually a generalist) assumes the service coordinator role and provides support to the family while supported by a team of other professionals (including therapists) who provide services to the child and family. Often the contacts are joint visits with the service coordinator. The service coordinators are the primary coach to caregivers and families reinforcing the strengths, assets, strategies and building capacity. This allows our most limited resources, the therapists, to concentrate on using their expertise more efficiently. Services may include blocks of intervention, group sessions, clinics, regular visits or monitoring children who are at risk for delays. Children wait no longer than a month from initial referral to receiving service. The frequency and level of intervention depends on the child and family needs and priorities. Services to families expand or decrease over time. The FVCDC strives to provide the right service at the right time through team decision making. The changes made have had a significant impact on the capacity, timeliness and quality of our early intervention services. Families indicate a higher level of satisfaction in the areas of having one consistent person over time work with them; they report that they receive consistent information from person to person and that the team plans and works together. Staff indicates that they support the overall direction of the agency and feel they have opportunities to have input into the work of the organization and recognize the strong focus on customer service by the agency. Recruitment of staff has also been positively impacted. The opportunity to work within a multi disciplinary team has drawn employees to FVCDC.