SRI International. An Analysis of Needs and Service Planning in the Texas Early Childhood Intervention Program. August 31, 2010.

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1 SRI International August 31, 2010 An Analysis of Needs and Service Planning in the Texas Early Childhood Intervention Program Prepared for: Robin Nelson, Ph.D. Texas Department of Assistive and Rehabilitative Services 4800 N. Lamar Blvd. Austin, Texas SRI Project: P19478 Prepared by: Kathleen Hebbeler, Ph.D. Sangeeta Mallik, Ph.D. Cornelia Taylor, Ph.D.

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3 Acknowledgments The authors would like to thank the many individuals who contributed to this project. We extend a special thank you to each of the early intervention professionals who prepared for the team study by reviewing case records for 22 children and families and then met all day as teams to discuss the records and make recommendations. We would also like to thank the ECI providers who participated in the telephone interviews and shared their thoughts on service planning and home visiting. Finally, a special thanks is extended to our incredible group of national experts, namely: Mary Beth Bruder, Pip Campbell, Angela Deal, Barbara Hanft, Mary Claire Heffron, Toby Long, Robin McWilliam, Dathan Rush, M Lisa Shelden, and Juliann Woods. Some of these individuals provided valuable contributions on the study design and data collection tools, and all of them shared their considerable collective expertise on early intervention service planning. It was a privilege for us to be able to work with everyone who contributed to the study and we thank each of them for their contributions.

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5 Contents Executive Summary The Need for Information on Amount of Services Service Planning in ECI Trends over Time Hours of Planned Service for Each Service Hours of Planned Service by Child Characteristics Patterns of Service Delivery Team Recommendations Background Findings Expert Decision Making Service Delivery Approach Decisions about Services Factors to Consider in Deciding Frequency and Intensity Structuring of Time with Families Conclusions References Appendices A. Methodology... A-1 B. Recommended Services Form... B-1 C. Interview Results and Protocol... C-1 D. Statistical Tests and Additional Tables... D-1 i

6 List of Tables Page 2-1. Total and Mean Hours of Planned Service for Each Type of Service for Initial IFSPs for March Mean Hours of Planned Service by Child Characteristics Frequency and Intensity of Planned Services for March Types of Service Planned Hours per Month of Service, by the Type of Team (N = 135) Total Amount of Planned Hours of Service per Month, by Type of Team and Child Eligibility Group List of Figures Page 2-1. Average Planned Service Hours per Child per Month Percentage of Children with Planned Services: FY05 FY Number of Children for Whom Each Service Was Planned, by Type of Team Mean Total Hours of Planned Service per Month, by Type of Team and Child Eligibility Group Median Discrepancies in Hours of Service per Month Across Different Teams, by Child Eligibility Group Mean Number of Planned Services, by Type of Team and Eligibility Group ii

7 An Analysis of Needs and Service Planning in the Texas ECI Program Executive Summary Texas like other states has faced an ever increasing challenge of trying to reach and serve all eligible children and families with a limited pool of resources available for early intervention services. Levels of planned and delivered services in the Early Childhood Intervention (ECI) program have been slowly but steadily declining over the past few years, despite indicators suggesting that many children and families have more complex needs than in the past. In 2009, the average amount of planned service was 2.7 hours per month. Other states report an average of 6.5 hours of early intervention service per month. Recognizing the probable impact of declining service hours on the quality of care, the Texas Department of Assistive and Rehabilitative Services (DARS) contracted with SRI International to study the current service needs of families participating in the ECI program. The project consisted of several studies that addressed the intensity of service that children and families are receiving and need to receive for ECI to be effective. One study used existing state data and two studies brought together interdisciplinary teams of highly experienced clinicians to review a sample of records of children and families receiving services through ECI. One of the team studies involved national experts, and another used clinicians in Texas. Teams were comprised of an early intervention specialist, a physical therapist, an occupational therapist, a speech language pathologist and either a social worker or licensed professional counselor. Each team reviewed intake, evaluation, and other information in the record and made independent recommendations on the type, frequency and intensity of service for the child and family. These teams were explicitly instructed to assume that they had the resources to provide children and families the services they need. Major findings are summarized below. Recommendations from National Experts. Two interdisciplinary teams of national experts in early intervention reviewed records and made service plan recommendations. In addition, the national experts provided guidance on factors teams should consider in reaching service recommendations. The experts suggested that 1 hour of service once a week represented a reasonable starting point for service planning discussions although in their own deliberations on a sample of the children and families, they never recommended less than this amount of service. 1

8 The experts stressed that providers should be spending their time with families by supporting the family in helping the child learn and develop. They emphasized that professionals, who must be skilled in principles of adult learning, need time to provide the family with guidance in how to embed intervention in everyday activities. They identified a variety of factors that IFSP teams should consider in deciding an appropriate frequency and intensity of service, including the nature and complexity of the child s needs, the complexity of the expressed outcomes for the child, the confidence of the family in the knowledge and skills required to address their child s needs, the complexity of the family s needs, the extent of their social support network, and the nature of the intervention strategies. The experts also advocated for creative variations in service patterns to better address the needs of children and families such as providing more intense or frequent service early in a family s early intervention experience and having providers from different disciplines conduct home visits together when the family s circumstances require more than one area of expertise. Recommendations from Experienced Clinicians in Texas. The second study involved highly experienced clinicians in Texas who were either current ECI program staff or had expertise in early intervention but were not currently employed as ECI program staff. Collectively, these teams reviewed the records of 135 children (and families) who had various types of disabilities or developmental delays. This study found: The teams consisting of professionals not currently working as staff in an ECI program recommended substantially more hours of service per month (average of 6.1 hours) than did the teams made up of ECI program staff (4.3 hours). Both types of experienced teams recommended more service than had been planned by the children s actual IFSP teams (2.5 hours). The differences in recommended amounts of service between the child and family s actual IFSP teams and the other teams were largest for the children with global delays and medical conditions. 2

9 DARS Data on Service Planning in ECI. Analyses of data reported by programs on all children in ECI indicated that: The distribution of early intervention services has changed over the last 5 years, with fewer children receiving speech language therapy, occupational therapy, and physical therapy. Meanwhile the number of children receiving developmental service has increased. Though there is not substantial variation in planned service levels, the amount of planned service per month varies slightly depending on the nature of the child s special needs and the child s age. Children with global delays have the most hours of planned service per month; children with only motor impairments have the least hours. Older children receive more planned service than young children. Two patterns of service planning are far more common than all other patterns. Nearly half the children and families in ECI have their most intense service planned at twice a month for 45 minutes or twice a month for 60 minutes. For more than half the children, this pattern represented their only service. The findings from this set of studies on IFSP service planning underscore the complexity of making good planning decisions. Individualization, a core principle of early intervention, puts a considerable burden on the clinical judgment of those who are making decisions about the nature and amount of service to provide. The information from both the national experts and the team study indicates that families in Texas are receiving less service than they should be. The findings emphasize the need for standards and guidance related to service planning to help providers, especially those who are new to early intervention, reach decisions that are consistent with the family s circumstances and preferences. The findings also address the need to systematically and intentionally address how to align the level of need for ECI services with the funding available. Providing an amount of service that is below recommended levels is not a viable strategy for addressing insufficient resources. Policy and program changes are needed to ensure that the ECI system in Texas provides services consistent with recommended practice and at a frequency and intensity that will provide families the support they need to achieve their intended outcomes. 3

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11 1. The Need for Information on Amount of Services Early intervention is a system of services and supports for families whose infants and toddlers have developmental delays or disabilities. States receive federal funding for early intervention services and must comply with the requirements of Part C of the Individuals with Disabilities Education Act. Over the last decade, the number of children and families receiving early intervention services has been increasing consistently across the country. There were 187,000 children served in the program in 1999 compared to 343,000 in The amount of federal funding for the program has not kept pace with the increase in the number served; over that same time period, the federal per child allocation has gone from $1,979 to $1,280 per child. This report contains the results of several studies that SRI International conducted to provide the Texas Department of Assistive and Rehabilitative Services (DARS) with information on the current level of need for service among families participating in the Early Childhood Intervention (ECI) program. The findings from these studies are intended to assist DARS as it considers programmatic and funding alternatives that would improve the quality of care for children and families and develops future guidance to assist programs in improving service planning. Texas like other states has faced an ever increasing challenge of trying to reach and serve all eligible children with a limited pool of resources available for early intervention services. Texas faces particular difficulties in trying to reach and serve all eligible children for several reasons: Significant growth, approximately 7% for each of the last several years, in the number of children and families receiving services. The average monthly number of children served in ECI has gone from 18,178 in fiscal year 2001 to 30,042 in fiscal year Resource levels that do not support adequate service levels. DARS is appropriated an average monthly amount of $467 per child served. Though overall state funding has increased in attempts to account for caseload growth, the average dollar amount spent per child in ECI has remained flat for a number of years. A complex contract payment structure with multiple federal, state, and local funding sources. With more children needing services but no corresponding increase in resources, all states have been forced to find ways to bring services more in line with resources. Some states have narrowed 5

12 their eligibility criteria making fewer children eligible for services, or reduced the amount of services provided to those who qualify, or both. Texas has not restricted eligibility but has seen a reduction in services provided. Levels of planned and delivered services have been slowly but steadily decreasing over the past few years, despite indicators suggesting that many children have more complex needs than in the past. In 2005, the average amount of planned service was 3.1 hours per month; by 2009, it was 2.7. National figures would be helpful in examining how Texas compares to other states. Many states do not know this information, but, when compared to those that do, Texas ECI is planning for a comparatively small amount of service. In a recent national survey of all Part C systems, the majority of states did not know the average number of service hours delivered per child per month. Of the 20 states that did know, the number of planned hours of direct service per child per month (excluding service coordination) ranged from 2 hours to 18 hours, with an average of 6.5 hours. The number of hours delivered per child per month (excluding service coordination) ranged from 1.5 hours to 18 hours, with an average of 5.8 hours (IDEA Infants and Toddlers Coordinators Association, 2009). The average number of hours of early intervention services received in Texas per child per month, excluding service coordination, was 1.9 in FY09. Older research also has found higher amounts of services being planned or provided to families than the current amount in Texas. An early study of 190 infants receiving early intervention in Massachusetts found families were receiving a mean of 6.8 hours of service per month (Shonkoff, Hauser-Cram, Krauss, & Christofk Upshur, 1992). Another study in nine communities in three states found a mean of 6.8 hours per month of service provided (Kochanek & Buka, 1998). In the late 1990s, the National Early Intervention Longitudinal Study (NEILS) found families were scheduled to receive a median of 6 hours of service per month (Hebbeler, Spiker, Morrison, & Mallik, 2008). NEILS also found the average expenditure excluding service coordination and eligibility determination to be $916 per month in 1998 (Hebbeler, Levin, Perez, Lam, & Chambers, 2009). An average of 12.1 hours of month of planned service was reported for Indiana in 1997 (Perry, Greer, Goldhammer, & Mackey-Andrews, 2001). In commentary provided on this last study, Kochanek (2001) noted that this level of early intervention intensity appears relatively small (p. 110) and wondered whether 12 hours a month was sufficient to produce benefits for children and families. Set against this body of evidence, there is no question that planned service hours for children and families in ECI in Texas reflect a low level of early intervention service. 6

13 IDEA requires the development of an Individualized Family Service Plan (IFSP) for each participating family. The law specifies the components of the plan including a statement of the child s present level of development, the outcomes to be achieved, and the services to be provided, including the frequency and intensity and of the services. Frequency refers to how often a service is provided, and intensity is the duration of each session. The law intends that the family s team plans for, and that the IFSP reflects the services that are necessary to meet the unique needs of the child and family to achieve the results or outcomes identified in the plan. The plan is to be developed jointly by service providers in partnership with the family, and the law requires that the plan be reviewed periodically and revised as necessary. The trend in Texas ECI s service levels raises concerns about why service amounts are declining and how adequately families needs are being addressed with so little service time. One hypothesis is that, either consciously or unconsciously, IFSP team recommendations are reflecting the services that can be provided within the limited financial and staff resources available. The data on amount of planned service indicates a need to understand the actual needs of children and families, the gap between those needs and current service levels, how teams are making decisions, and how families are being served with such a relatively small amount of planned service. This series of studies focused on the amount of time a service is provided, but it is readily acknowledged that time is only one feature of effective early intervention. There is widespread consensus among early childhood professionals that what occurs during face-to-face contact between a professional and a family is more important for the potential impact of an early intervention service than the amount of time. Sixty minutes of quality service will be far more effective than 90 minutes of poor service. There also is consensus that more is not necessarily better even if more involves high-quality service. One of the goals of intervening is to help families support their child s development through daily routines and everyday learning opportunities (Sandall, Hemmeter, McLean, & Smith, 2005; Workgroup on Principles and Practices in Natural Environments, 2007). This is unlikely to happen if professionals are spending many hours a week with the family disrupting their everyday routines. Although many of hours of service is not considered quality service delivery, too little time also raises concerns. Logic dictates that there is some floor with regard to face-to-face time below which the capability of the provider to make a difference for the child and family is markedly lessened no matter how competently or efficiently that service is provided. At some point, the increment of time will become so small that a service cannot possibly achieve its intended outcome. 7

14 Identifying an ideal or even recommended amount of direct service is challenging for numerous reasons. One is that research on contact time as one of the ingredients of effective service is lacking (Noyes-Grosser et al., 2005; Palisano & Murr, 2009; Warren, Fey, & Yoder, 2007). Research has addressed various kinds of practices and interventions but generally not how much time it takes to deliver them or how much a practice as researched can be altered before it is no longer expected to have an effect. A second reason is that the needs and strengths of children and families being served in early intervention are so diverse. For many years, we have known that the right question is not whether early intervention is effective but what works for which children and families under what circumstances (Guralnick, 1997). The implication of this second generation question is that one size will not fit all with regard to any aspect of service delivery, including the frequency and intensity of time that a service provider and family need to spend together for early intervention to positively affect child and family outcomes. A third reason for how difficult it is to provide guidelines on amount of service involves the model of service delivery in early intervention. Current recommended practice in early intervention recognizes that the power of intervening in the child s development will come from how the parent interacts with the child and structures that child s environment (Sandall et al., 2005; Workgroup on Principles and Practices in Natural Environments, 2007). Quality early intervention means providing appropriate supports to parents so they can help their child learn and develop. How much time is required to provide that support depends on a complex interaction of child needs and family characteristics and circumstances. Questions about intensity of services are not unique to early intervention. Palisano and Murr (2009) discuss the controversial nature of the intensity of physical therapy and occupational therapy services for children and youth. They note that perspectives on intensity of therapy often vary considerably among families, therapists, administrators, policymakers and health insurers. Factors such as availability, accessibility, and cost enter into decisions on the intensity of therapy. Both IDEA and recommended practice stipulate that early intervention services be individualized. In practice, individualization should translate into some families needing and receiving more services and support. The diversity of the children and families in early intervention and the need to individualize services mean there is not one right amount for early intervention services but different right amounts for different families based on child and family characteristics. In the absence of a right amount, it is challenging but still important to ensure that families are receiving the amount of services they need to promote the optimal development of their child (Hanft & Feinberg, 1997; Kochanek, 2001). Providing guidelines on amount of service is critical in times of 8

15 difficult fiscal decisions to ensure that services are not being diluted to such a level that the resources are being wasted and are ultimately of benefit to few or no children and families. Because issues related to minimal levels of services have not been addressed in the literature, this project collected several kinds of information to assist DARS in setting policy and developing guidance around service planning. The research that would be needed to thoroughly examine the amount of service that should be planned for different children and families, such as comparing outcomes of similar children under different levels of service, was well beyond the scope, timeline, and resources available for this project. Rather, our approach involved documenting service variation, systematically exploring and documenting the clinical judgment of early intervention professionals from various backgrounds regarding the recommended intensity of face-to-face service for children with different patterns of delays and disabilities, identifying the factors influencing decisions about amount of service, and exploring providers perceptions of service planning and service delivery. For the most part, the information in this report focuses on planned services. Planned service refers to the type and amount of service families are scheduled to receive through ECI as specified on their IFSP. It is well established that families rarely receive all the services that are planned (Perry et al., 2001). NEILS, the national study of early intervention, found that families received about 75% of the services they were scheduled to receive (Hebbeler et al., 2008). A study in Indiana reported families received 61% of planned services (Perry et al., 2001). Currently in Texas, families receive about 75% to 80% of what is actually planned. Planned service represents the maximum amount of service a child and family could possibly receive; in reality, they will receive less. The analyses in this report focus on planned services because the program has control over the amount of service that is planned. There are myriad reasons why families do not receive all the service planned for them; understanding and addressing these reasons is essential for effective service delivery. However, why families do not receive all planned service is a completely different question than what influences service planning. To examine the relationship between resources and service planning, we have restricted our focus to planned services. Knowing that families almost always receive less service than they are scheduled to receive reinforces the importance of planning for sufficient services. If a family is only to receive two visits a month and misses one of them, they will be receiving very little service for that month. 9

16 The project consisted of a series of studies that across them employed multiple sources of evidence to address the intensity of service that children and families are receiving and need to receive for ECI to be effective. The first study used data currently collected by DARS to examine patterns in service provision statewide. The second study used teams of experienced professionals in Texas who were brought together to serve as IFSP teams and reviewed intake, evaluation, and other information on children and families currently receiving early intervention to make recommendations on the type, frequency, and intensity of service the child and family should be receiving. Another study involved case review and discussions with national experts. The next three chapters present the findings from each of these studies. The methods for these studies are described briefly in the chapters with more information provided in Appendix A. An additional study used telephone interviews with professionals working in the ECI system to learn what factors they consider in making recommendations for services and also to learn about what they were doing during the time they spend with families. The results of this study are presented in Appendix C. 10

17 2. Service Planning in ECI One rich source of information on service planning within ECI is the data that programs report to DARS. Information from the IFSP including the type of service (e.g., speech therapy), the frequency (number of times over a time period, such as 4 times a month), and intensity (length of time for the service, such as 30 minutes) is reported for all initial IFSPs and revised IFSPs as those change over time. In this chapter, we address a variety of issues related to planned services including trends over time and across other factors. These analyses provide what is known about how ECI programs are approaching service planning and set the stage for the rest of the report. Trends over Time As noted in Chapter 1, the amount of planned service in ECI has been declining over time. Figure 2-1 shows the average total amount of planned hours per child per month from 2004 to The average total amount of planned service was 3.2 hours per month at the beginning of 2004 and 2.8 hours by The planned amount has increased slightly since 2009 when it reached a low of 2.5 hours, but it is still lower than it was 6 years ago. Figure 2-1. Average Planned Service Hours per Child per Month Several different kinds of services are available in early intervention, so the decline might be reflected evenly in all services, or some services may be contributing more to the decline than others. Figure 2-2 presents the percentage of children who were scheduled to receive each of the five most 11

18 frequently provided EI services for the years 2005 through The percentage of children for whom developmental service was planned has increased in the last 5 years from 71% to 79%. During this same period of time, the number of children for whom speech language therapy was planned has declined from 50% to 41%. Similarly, the percentage of children scheduled to receive occupational therapy has declined from 30% to 22% and to receive physical therapy, from 24% to 16%. The percentage of children and families with planned nutrition services has remained constant at about 10%. Figure 2-2. Percentage of Children with Planned Services: FY05 FY10 Several hypotheses could explain the change in service planning over the last 5 years. One is that the nature of the population has changed so that the children currently in ECI have less need for the therapy services than children did 5 years ago. There is no evidence to suggest that this is so; to the contrary, the needs of the population seem to be getting more complex, suggesting an increased need for these services. For example, for children with developmental delays, the percentage with delays in multiple areas has increased from 37% in 2004 to 59% in The number of children with autism spectrum disorders has more than doubled in that same period of time. Another hypothesis is that the shortage of therapists in ECI programs continues to worsen, and that programs compensate for this shortage by planning for fewer children each year to receive one or more of these therapies. A recent analysis of ECI s contract structure documents the challenges that 12

19 ECI programs face in hiring and retaining both physical therapists and occupational therapists. A third possible explanation is the limited funding that has been appropriated per child served in the program, and the fact that the average dollar amount spent per child has remained flat over a number of years. Considering inflation factors, flat funding effectively results in a decrease in the ECI programs purchasing power. Hours of Planned Service for Each Service To further examine differences across the different early intervention services, we looked at the amount of service children and families were scheduled to receive. Interestingly, the median amount of service planned for the four more frequently planned services (developmental service, speech language therapy, occupational therapy, physical therapy) was identical at 1.5 hours per month (see Table 2-1). A major difference in the four most frequent services is in how many families have IFSPs with the service, not in the mean amount of it they will be receiving. The mean amount of planned time for developmental service was higher than the median (1.9 compared to 1.5) indicating that some children and families had plans that called for more developmental service than for others. The planned hours of developmental service ranged from a low of.02 hours a month (a consultation) to 12 hours a month. The median amount of monthly service for the less frequently planned services varies greatly from.8 hours for health, medical and nursing services to 3 hours for audiology. Table 2-1. Total and Mean Hours of Planned Service for Each Type of Service for Initial IFSPs for March 2010 Service Category Total Hours Planned for a Month Number with Service Mean Median Developmental Services 12,697 6, Occupational Therapy 1,500 1, Physical Therapy 1, Speech Language Therapy 4,247 2, Nutrition Psychological / Social Work Family Education and Training Audiology Vision Behavioral Intervention Health, Medical, Nursing TOTAL 20,577 8,

20 Hours of Planned Service by Child Characteristics Several characteristics of children were examined to determine whether planned service levels differed across the dimensions of eligibility type, type of delay or disability, and age of the child. Children are eligible for ECI if they have a medically diagnosed condition that results in a high probability of delay; developmental delay in one or more domains, such as speech, motor or cognition; or atypical development in one or more areas. The average (mean) planned hours per child are presented in Table 2-2. The mean planned hours is highest for children with developmental delay and lowest for children with atypical development. In addition to these three broad eligibility types, we also looked at children in terms of the areas of delay and whether they had one or more areas of delay. We identified five different groups of children for this analysis: (1) children with motor delay only, (2) children with speech delay only, (3) children with speech delay and delay in one other area, (4) children with global delay, defined by delays in three or more areas (e.g., speech, motor, cognition, social/emotional, and adaptive/selfhelp), and (5) children with the most prevalent medically diagnosed conditions (e.g., Down Syndrome, cerebral palsy, spina bifida). The mean planned hours for each of these groups is presented in Table 2-2, and results indicate that children with global delay had the highest mean planned hours and children with motor delays only had the lowest mean planned hours of services. Table 2-2. Mean Hours of Planned Service by Child Characteristics Characteristics Number Mean Eligibility Type Atypical Development 1, Developmental Delay 6, Medical Diagnosis Type/Areas of Delay Motor only 1, Speech only 2, Speech plus one other area 1, Global 2, Medical Diagnosis Age at Enrollment 0 to 1 2, to 2 2, to 3 3,

21 Another factor examined was age of the child at enrollment in services. As also seen in Table 2-2, the mean hours of planned service hours increased with the age of the child. It is important to note that younger children are more likely to be eligible because of atypical development, so there is a relationship between age and eligibility type. Patterns of Service Delivery The total hours of planned monthly service are derived from two numbers: the number of times a month the service will be provided (frequency) and the length of time for the service (intensity). Two hours of a planned service could be planned as 1 hour 2 times a month or 30 minutes 4 times a month. To learn how teams are allocating planned services, we examined service patterns along with the frequency and intensity. This analysis used the service with the most time on the IFSP for all IFSPs that were active in March We also looked at initial IFSPs only to see if there were differences in how services were planned when the providers had not had much time to get to know the child and family. Three patterns of service describe how most services are being delivered: twice a month for 45 minutes (1.5 hours of service a month), twice a month for 60 minutes (2 hours), and four times a month for 45 minutes (3 hours) (see Table 2-3). The primary planned service followed one of these three patterns on 59% of all IFSPs. Each of the other patterns applied to 7% or fewer of the IFSPs. With regard to frequency, exactly half of the IFSPs had the primary service planned for twice a month, another 20% were planned at four times a month and 17% were planned for once a month. Over half the IFSPs had services planned for 45 minutes (56%), 33% of services were planned for 60 minutes and another 10% for 30 minutes. As can be seen clearly in the table, initial IFSPs did not differ from the entire group of IFSPs with regard to pattern, frequency, or intensity suggesting that programs do not adopt fundamentally different frequencies or intensities as the providers and families become better acquainted with one another or as changes occur in the child or family. To further explore patterns of service planning, we looked at the number of children receiving more than one service (see Table 2-4). For 60% of the children and families, the service pattern described in Table 2-3 represented their only service. The other 40% had more than one service and nearly all of them were receiving just one additional service. 15

22 Table 2-3. Frequency and Intensity of Planned Services for March 2010 All IFSPs Initial IFSPs Overall Pattern Hours per Month Number Percent Number Percent 2 times per month for 45 minutes 1.5 8, , times per month for 60 minutes 2 5, , times per month for 45 minutes 3 4, , times per month for 60 minutes 1 2, times per month for 45 minutes , times per month for 45 minutes , times per month for 30 minutes 1 1, times per month for 60 minutes 4 1, times per month for 30 minutes times per month for 60 minutes times per month for 30 minutes All other combinations 1, TOTAL 31, ,214 Frequency 1 time per month 5, , times per month 15, , times per month 3, , times per month 6, , Other 1, Intensity 30 minutes 3, , minutes 17, , minutes 10, , Other Table 2-4. Number of Planned Services for March 2010 Number Percent One service 5,064 60% Two services 3,162 38% Three services 162 2% Four or more services 30 <1% 16

23 3. Team Recommendations Background The purpose of the team study was to examine service planning decisions made by independent, experienced teams of clinicians. These independent teams of early intervention professionals reviewed records of children currently in the ECI system and made recommendations for services, which were then compared to the actual services planned by the child s IFSP team. This study involved the collection and comparison of service recommendations for 135 children who entered ECI in late 2009 to early For each of these children, the original IFSP team had developed an initial IFSP, which included recommendations for type, frequency, and intensity of service. For this study, each child s record was later reviewed by two other interdisciplinary teams who also made recommendations for the type, frequency, and intensity of service. One of the additional teams was made up primarily of professionals who were employees of ECI programs and currently providing EI in Texas (referred to as an internal team). They were not part of the child s IFSP team and, for most of the children, were not even from the program serving the child. A second team, comprised primarily of professionals who were not employed by an ECI program (referred to as an external team ), also reviewed the records. The external teams included professionals who work in other pediatric settings, such as private practice or hospital settings; teach and practice in a university setting; or work in other public settings, such as local school districts. Some also work as contract providers and in this capacity may provide early intervention services. All members of the internal and external teams were professionals with extensive clinical experience providing early intervention services. Eight internal and eight external teams each reviewed a different set of 21 or 22 case files and met in person to discuss each child and family and make their recommendation. The internal and external teams were convened in Dallas (six teams), Houston (six teams), and Austin (four teams) to discuss the children assigned to their team and to make their service plan recommendations. The design called for all of the teams to be made up of an early intervention specialist, a speech language pathologist, an occupational therapist, a physical therapist, and either a social worker or licensed professional counselor. Nearly all teams had these five disciplines represented except for a few teams where circumstances prevented an individual from being present on the day of the meeting. The 17

24 internal and external teams were specifically instructed that they were to assume the program had all of the resources needed to provide the services the team considered appropriate for the child and family. A potentially important difference across the teams was that child s family was present for the actual IFSP discussion and obviously the family was not present when the independent teams discussed the child and family s information and formulated service plan recommendations. Although the family was not present, teams did have access to intake information, screening results, evaluation results, family concerns and resources and other information as reflected in the record. Not having complete information about the child or family was more of a limitation for some children than others, depending on what was in the record and how much more the team wanted to know. The sample of records consisted of 135 children selected from nine programs and representing five groups of children, based on reasons for eligibility for services and areas of delay: (1) children with motor delay only, (2) children with speech delay only, (3) children with speech delay and delay in one other area, (4) children with global delay, defined by delays in three or more areas (e.g., speech, motor, cognition, social/emotional, and adaptive/self-help), and (5) children with the most prevalent medically diagnosed conditions (e.g., Down Syndrome, cerebral palsy, spina bifida). Collectively, these five groups represent more than 80% of all children served in ECI in Texas. The complete record for each child was copied, up to and including the initial IFSP, except for the page documenting service, frequency, and intensity. All information that identified either the child or the program was blacked out of the record. Each team had access to its set of records prior to the meeting so it could review the records in preparation for the team discussion. The presentation of the findings compares service type and amount recommendations from the three teams: the IFSP team who developed the actual recommendation for planned service and the internal and external teams who reviewed the same record. Appendix B contains the form on which the internal and external team recommendations were recorded. Additional tables and the information on the statistical significance of the comparisons presented in this chapter are contained in Appendix D. All differences described are statistically significant at the.05 level or less. Findings Overall, the analyses show substantial differences in the type, number, and amount of planned service across the three teams. The IFSP team was more likely to recommend developmental service 18

25 than the other two teams, whereas the other two teams were more likely to recommend therapy services. The IFSP team also planned for substantially fewer minutes of service than the internal team who planned for less than the external team. The differences across the teams in minutes of services were greatest for children with global delays and medical conditions. Type and amount for each service. The first analysis addressed how many children and families were recommended for each type of service. Recommendations for evaluations were not included when computing type, amount of service, or number of services. For those children for whom the team recommended a particular service, we then computed the average number of hours that the team recommended for that service. The IFSP teams had included developmental service on 93 of the 135 IFSPs (see Table 3-1 and Figure 3-1). The internal teams planned developmental service for 79 of the children, and the external teams for 82. For two of the three therapies, speech and occupational therapy (OT), the external and internal teams recommended the service for more children than did the IFSP team. The difference is particularly striking for speech therapy as shown in Figure 3-1. The IFSP teams planned speech services for 26 children, the internal teams indicated 49 children as needing the service, and the external teams had 70 children for whom they recommended speech therapy. Table 3-1. Planned Hours per Month of Service, by the Type of Team (N = 135) Service Planned Amount of Planned Service Number* Percent Mean Median Developmental Service IFSP Team Internal Team External Team Speech Therapy IFSP Team Internal Team External Team Occupational Therapy IFSP Team Internal Team External Team Physical Therapy IFSP Team Internal Team External Team * Number refers to how many of the 135 children the team thought should receive the service. Evaluations were not included in the analysis. 19

26 The teams also recommended other types of services, but all teams recommended these other services for far fewer children and families. After developmental service and the three therapies, there were four other planned services (nutrition, behavioral intervention, family education/training/counseling, and social work) recommended by the IFSP teams. Each of these services was listed on one out of the 135 IFSPs. For the internal team, the most frequently planned service after developmental services and the three therapies was nutrition, which was recommended for 9 families. For the external team, the next most frequently planned service was social work services, which the external team recommended for 11 families. In sum, developmental service and the three therapies were the core services recommended by all three types of teams. The difference across teams was in how many children and families the teams saw as needing these core services. Figure 3-1. Number of Children for Whom Each Service Was Planned, by Type of Team In addition to looking at how many children and families the teams saw as needing to receive each of the services, we also looked at the amount of time planned for each service. As shown in Table 3-1, there were large differences across the teams in the number of planned hours of each service. The internal and external teams recommended more hours of service than the IFSP teams 20

27 although these differences were much larger for some services than for others. The differences are especially striking for speech services, where the external team recommended an average of 3.5 hours of speech therapy per month compared to 2.6 hours from the internal team and 1.8 hours from the IFSP team. The pattern was similar for occupational therapy. There were no meaningful differences across teams in the amount of planned time for physical therapy. For all of the comparisons related to the team findings, the medians are presented in the tables along with the means. For comparing team recommendations for hours of each of the services and for other comparisons presented in this chapter, the median, the middle number across the 135 children, sometimes conveys a finding similar to the mean and sometimes a different finding. The mean will be higher than the median if an unusually large amount of service was recommended for one or more of the children and families. When this happens, the recommendations for a small number of children will increase the mean differences between the teams. In reporting the findings, we will call attention to differences between the mean and median when these occur. With regard to developmental service, Table 3-1 shows that the internal and external team had the same mean recommendation (2.6 hours), which was more than the IFSP teams recommendation (2.2 hours), but that the IFSP and internal teams had identical median recommendations for developmental service (2 hours) and both were lower than the external team at 3 hours. The analysis of the data on individual services showed that the internal and external teams were more likely than the IFSP team to recommend therapy services and that the IFSP team was more likely to recommend developmental services for the same set of children. For three of the four core services (developmental service, speech, and OT), the internal or external team or both recommended more hours of service per month than the actual IFSP team. Total amount of planned service. The analyses just presented looked at each service individually. To compute a total amount of planned service for each child for each team, the number of planned hours per month for each service was added across all services. For example, an IFSP with 1 hour of developmental service and.5 hours of speech therapy per month has a total amount of planned service of 1.5 hours per month. The mean total amount of service recommended by the IFSP teams was 2.5 compared to 4.3 hours by the internal teams and 6.1 hours by the external teams (see Table 3-2 and Figure 3-2). The medians of all three team types were lower than their means, but the pattern is identical for the 21

28 means and medians with the IFSP team planning for less service than the other two team types. Additional information on differences in total amount of service is presented in Appendix D. We looked at the total amount of service per month for each of the five eligibility groups to see whether the nature of the child s eligibility influenced service planning (also shown in Table 3-2 and Figure 3-3). There were several findings with regard to child eligibility group. First, the pattern of the external teams recommending more total service than the internal teams and the internal teams recommending more than the IFSP teams held across all five Table 3-2. Total Amount of Planned Hours of Service per Month, by Type of Team and Child Eligibility Group N Mean Median Overall (N = 135) IFSP Team Internal Team External Team Child Eligibility Group Global (N = 27) IFSP Team Internal Team External Team Medical (N = 27) IFSP Team Internal Team External Team Motor Only (N = 27) IFSP Team Internal Team External Team Speech Only (N = 27) IFSP Team Internal Team External Team Speech Plus (N = 27) IFSP Team Internal Team External Team

29 eligibility groups for the mean hours of planned service with two exceptions. The internal and external teams did not plan reliably different amounts of service for children with global delays and motor delays. The difference between the two teams for children with global delays was quite large but did not reach statistical significance because of the large range in the external teams recommendations. The differences between the IFSP teams and the other teams were largest for the children with global delays for whom the other teams recommended nearly 3 (internal team) to 6 Figure 3-2. Mean Total Hours of Planned Service per Month, by Type of Team and Child Eligibility Group (external team) hours more service per month than did the IFSP team. The children with medical conditions also received substantially more planned service time from the internal and external teams compared to the hours planned by the IFSP team. A second finding from these data is that both the external and internal teams recommended amounts of service that differed based on eligibility group whereas there were no reliable differences by eligibility group for the IFSP teams. One possible interpretation of this finding is that while all children and families may be receiving a smaller amount of service than they should be, the impact of not enough service time is unevenly distributed across the groups. The two groups most impacted are the children who could be considered to have some of the most serious needs: those with global delays and those with medical conditions. 23

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