Ensuring Progress for All Children & Families J A C K I E C - - PDF document

10/14/18 1

Ensuring Progress for All Children & Families

J A C K I E C R I S W E L L , W E N DY P I T TA R D, & L A U R A S C H E RT Z

Objectives

• Identify factors that might contribute to a lack of progress
• Have strategies for difficult conversations with families &

caregivers

• Learn the Routines-Based Home

Visitor script

• Understand how continuing services when there is little

progress still matches up with AEIS as well as OT, PT, & SLP professional statements

Presentation Outline

• What does it look like?
• Difficult Conversations
• Small Group Scenarios
• Home

Visit Script

– Strategies for intervention problem solving

• Professional Statements
• Questions/Discussion

10/14/18 2

What does progress look like? What does it look like when little progress is being made?

Difficult Conversations

“The” Conversation

PREPARE DISCUSSION

• Prepare TIME
• Prepare the WHO
• Prepare DATA
• Prepare RESOURCES
• Prepare for EMOTIONS
• Discuss the POSITIVE
• Discuss OBSERVATIONS
• LISTEN
• Discuss what comes NEXT
• Discuss RESOURCES

10/14/18 3 Tough Questions/Situations

• Does my child have Autism?
• Did I cause this delay?
• Can I have a different service provider?
• Is EI right for this family?

Early Intervention Children’s Rehabilitation Services Local School System Early Head Start Parents as Teachers Help Me Grow Private or Outpatient Therapy

Small Group Scenarios

10/14/18 4 Small Group Scenarios

• What difficult conversations would you anticipate with

each small group scenarios & share personal experiences

• What are the roadblocks to progress?

Avery - Scenario #1

Avery is an 18 month old girl and her family has been receiving Early Intervention services for a few months now. Avery’s current service provider is a speech-language pathologist, Brittany. The visits have been at home with Avery & her mom, Helen. Helen seems fairly quiet during the home visits with Brittany. Brittany has a very bubbly personality & children are usually entertained by her excitement during home visits. She makes sure that she uses lots of big gestures, uses a loud voice, & varies her intonation a lot during home visits. She shows Helen how to do this as well & these are some of the strategies she leaves with Helen. Whenever she asks Helen about how the strategies have been going, Helen typically says that she tried them & they didn’t work or that she didn’t have time to try them. Avery doesn’t seem to be making as much progress as Brittany thought that she might. Brittany is beginning to feel that Helen might not be attempting many of the suggested strategies.

Zack - Scenario #2

Zack is 2 years old and recently referred for Early Intervention services. He is an active little boy and lives at home with both parents & his new baby brother. Parents’ primary concerns include Zack’s limited communication skills (previously said 2-3 words, but now does not use any words functionally), sleeping better at night, & eating more. Mom reports they follow an attachment parenting style. The family bedshares, she nurses Zack (often tandem nurses with his baby brother), avoids telling Zack “no,” & does not like to make him do things he doesn’t want to do. Zack has a lot of sensory seeking behaviors, as well as negative behaviors as a result of frustrations with communication & to receive

• attention. He has recently started hitting his baby brother. OT and mom have

come up with many activities to provide sensory input & mom is implementing them throughout the day. However, mom will not implement any recommendations that involve guidance, boundaries, redirection, or age- appropriate, research-based discipline (i.e., time out). The family is also very reluctant to add more structure to their day to build routines to support Zack’s participation in mealtimes & bedtime. They let him graze throughout the day & he goes to bed around 11:00pm, when his parents do. How do you proceed?

10/14/18 5 Miguel - Scenario #3

Miguel is 15 months old and lives at home with mom, 2 aunts, an uncle, and his maternal grandparents. Miguel is included in all family activities and is well-cared for and very well-loved. The female caregivers in his life (mom, 2 aunts, & grandmother) all share the responsibility of caring for him, carrying him around, and meeting his needs. They use the pack-n- play to keep Miguel safe from all of the traffic in the home, fearing that he would be stepped on if left on the floor to play since he can’t move

• ut of the way yet. Miguel’s family believes their role in child rearing is to

take complete care of him and ensure his safety. Developing his independence is not a priority for them as he is considered a baby for the first few years of his life. Mom says she wants him off the bottle, but reports that Grandma & his aunts continue to give it to him.

Kelly is 26 months old and has a diagnosis of holoprosencephaly. She lives at home with both parents. Mom stays home with Kelly during the day. Kelly has a trach, g-tube for all nutrition, and has multiple seizures on a daily basis. She has been receiving PT, OT, & vision services through EI since 3 months of age. Some of the IFSP outcomes have stayed the same during her time in EI –

• pening & closing her fingers to hold onto items, allowing for

mouth/teeth cleanings, & looking at her family to interact with

• them. The OT voiced concerns to the service coordinator that

they’ve been addressing the same outcomes for awhile now, with no change in performance. What would you recommend?

Kelly - Scenario #4 Tommy - Scenario #5

Laura is a single mother with two-year-old little boy, Tommy. Tommy has been receiving EI for three months. Laura is concerned about his communication &

• behavior. Tommy gets very upset when he can’t tell Laura what he wants & will

have a tantrum. Laura and Tommy’s SI have been working on Tommy using words & following directions. Laura and Tommy have been living with Laura’s parents for the past year. Grandpa gets up for work early and goes to bed early. Laura works hard to keep Tommy quiet in the evening, so Grandpa can sleep. Grandma keeps a very tidy house and does not like messes or having Tommy’s toys out around the house. Grandma is retired and watches Tommy while Laura works three days a week. Grandma thinks that Tommy will talk when he’s ready and that there is nothing to worry about. At the first EI visit, she made a point of telling the SI that she has raised 5 children and 3 were late-talkers and they are fine now. She wonders – out loud – if early intervention is just a scam to get insurance

• money. She also has a more authoritarian parenting style than Laura and says that

all that Tommy needs is a good spanking when he has a tantrum.

10/14/18 6 Olivia - Scenario #6

Olivia (10 months old), has been receiving EI for two months for motor concerns. She lives at home with her mom, Tasha, three siblings (all under four years old), and Tasha’s boyfriend. When the PT arrives for a visit with the family, Tasha opens the door & the PT notices that there are no lights on in the house. There is also a strong odor of dirty diapers. Tasha said that she tried to call & cancel the appointment because the power has been turned off, but her phone was out of minutes. The PT is able to talk with Tasha through the door for a bit & then Tasha invites the

• PT. Tasha removes the cover on the window, so that some light

comes in the room. The PT notices that even though it is lunch time, Olivia has a saggy, full diaper. PT also notices that the box

• f diapers that usually sits next to couch is empty.

Home Visit Script

• 1. General Well-Being:
• 2. New Questions or

Concerns:

• 3. Outcomes in Priority

Order:

• 4. Problematic Routines:
• 5. Other Family

Members:

• 6. Appointments:
• 7. Work Load Related to

Intervention:

• 8. Follow-Up Prompt’s:

The 4 E’s

How have things been going? Do you have anything new you want to ask about? How have things been going with (each IFSP

• utcome, in priority order)?

Is there a time of day (or specific activity) that’s not going well for you? How is (family member) doing? Have you had any appointments in the past week? Any coming up? Do you have enough or too much to do with (your child)? Ears (listen), Elicit (ask), Empathize, Encourage

Home Visit Script Overview

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Intervention Problem-Solving: A Framework for the Home Visit Script

• How’s it going with each outcome? (Question 3 from Home

Visit Script)

– Child can do it!! – Child is improving – Not much improvement

• Strategies for intervention problem-solving

– Ask-to-suggest – Demonstration (modeling steps) – Refine skill – Tweak implementation – Persist

• Change intervention
• Change routine
• Matrix
• Up the ante

How’s it going with each outcome? Not much improvement

• What/how is the child doing?

– Get a description of what it looks like

• If intervention not previously planned/discussed:

– Ask for demonstration of child trying – Use Ask-to-Suggest

• “Have you tried this? Have you tried that?”

– Offer to demonstrate & model steps

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8 Steps of Modeling: Avoiding the “Model & Pray” Approach

• 1. Talk to the parent about your suggestion
• 2. If they don’t seem to understand, would they like to be shown?
• 3. Tell the parent what you’re going to do
• 4. Do it
• 5. Tell the parent what you did & point out the consequence
• 6. Ask if they would like to try
• 7. If yes, watch them trying it; if no, leave it alone
• 8. If yes, praise the parent & give limited corrective feedback

Evaluation of the Intervention: When not seeing much improvement

• If intervention was already planned/discussed:

– Ask “How is the implementation going?”

• If they ARE implementing the intervention…

– Family describes & demonstrates what they’ve been doing

• Refine the skill or Tweak implementation
• If they are NOT implementing the intervention… WHY??

– “Hard to fit into routine”: Change intervention or Change routine – Child isn’t responding : Change intervention or Persist – “Forgot to do it” : Matrix – “Didn’t know how” : Demonstrate/Model

When family issues come up…

• Is it a resource need? Intrafamilial need? Other need?
• Has an strategy/intervention previously been planned?

– If yes, change:

• Outcome/goal
• Criterion
• Strategy (intervention)

– If no, problem solve with family:

• Can they use informal sources of support to meet the need?
• Should the home visitor listen & advise?
• Do they need change in services or referral to formal source of

support?

10/14/18 9 Small Group Scenarios

• Strategies to work through the situation?
• Personality Conflicts
• Cultural Differences
• Medically Involved
• Family Influence
• Socioeconomic

Professional Statements

Alabama’s Early Intervention System

• Early intervention supports & services focus on teaching

the parents & other caregivers ways to help the child learn & participate in everyday activities.

• Trains/Equips the Parent/Caregiver

AEIS is a program that supports & trains families &

• caregivers. EI will aid & support your family while

teaching you skills to meet your child’s developmental

• needs. With the support of your team of professionals,

together we will work to carry out these activities on a daily basis so that your child & your family will meet your outcomes.

10/14/18 10

Jimmo v. Sebelius Corrective Action Order “Skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program.”

• Sought to dispel the fallacy and provide clarifications to safeguard against unfair

denials by Medicare contractors for skilled therapy services that aid in maintaining a patient's current condition or to prevent or slow decline.

• http://www.medicareadvocacy.org/wp-content/uploads/2017/02/Jimmo-v.-Sebelius-Corrective-Action-Order.pdf
• http://www.apta.org/Payment/Medicare/CoverageIssues/SkilledMaintenance/
• https://www.asha.org/practice/reimbursement/medicare/documentation-of-skilled-versus-unskilled-care-for-

medicare-beneficiaries/

Questions??

Contact us!

jackie.criswell@rehab.alabama.gov wendy.pittard@rehab.alabama.gov lschertz@childsplaytherapycenter.com