Implementing a Primary Coach Approach to Teaming M’Lisa Shelden, PT, PhD Family, Infant & Preschool Program Morganton, North Carolina Mlisa.shelden@ncmail.net Dathan Rush, EdD, CCC-SLP Dathan.rush@ncmail.net http://www.coachinginearlychildhood.org

Evidence-Based Paradigm Promotion Capacity-building Strengths-based Resource-based Family-centered Dunst, 2000

Operational Definition of the Primary Coach Approach The primary coach approach to teaming is when one member of an identified multidisciplinary team is selected as the primary coach, receives coaching from other team members, and uses coaching with parents and other care providers.

Characteristics of Primary Coach An identified team of individuals from multiple disciplines having expertise in child development, family support, and coaching is assigned to each family in the program. One team member serves as primary coach to the care provider(s). The primary coach receives coaching from other team members through ongoing planned and spontaneous interactions.

Primary Coach – Implementation Conditions All therapists and educators on the team must be available to serve as a primary coach.

Primary Coach – Implementation Conditions All team members attend regular team meetings for the purpose of colleague-to-colleague coaching. Coaching topics at team meetings are varied and include specific information for supporting team members in their role as a primary coach to the families in the program.

Team Meeting Guidelines One team member serves as team meeting facilitator Announcements are provided in written form and not discussed Scheduling occurs at the end of the meeting Families know when/why their primary coach brings questions to the team meeting No decisions are made at team meetings without parents When families participate, meetings are held at convenient times & locations for the family

Primary Coach – Implementation Conditions The primary coach is selected based upon desired outcomes of the family, rapport/relationship between coach and learner, and knowledge and availability of the coach and family.

Primary Coach – Implementation Conditions Joint visits should occur at the same place and time whenever possible with/by other team members to support the primary coach.

Primary Coach – Implementation Conditions The primary coach for a family should change as infrequently as possible. Justifiable reasons for changing the primary coach include a request by a family member or other care provider; or when a primary coach believes that even with coaching from other team members he or she is ineffective in supporting the care providers.

Implementation Tools Primary Coach Rating Scale Team Meeting Agenda format Team Meeting Minutes format http://www.coachinginearlychildhood.org http://www.fippcase.org

Characteristics of Teaming Teams should consist of individuals who: are agreeable are conscientious have high general mental ability are competent in their area of expertise are high in openness to experience and mental stability like teamwork have been with the organization long enough to be socialized (Bell, 2004) (cont.)

Characteristics of Teaming Team task(s) should allow members to use a variety of skills (Bell, 2004) Team task(s) should result in meaningful work (Bell, 2004) Team’s work should have significant consequences for other people (Bell, 2004) Team should generate feedback about how the team is performing (Bell, 2004) Number of team members should be appropriate for the task (Bell, 2004; Larsson, 2000) Teams should have some degree of self-managing abilities (Bell, 2004) Teams should have a common planning time (Flowers, Mertens, & Mulhall, 1999)

Strategies for Establishing a Team A team must consist of a team leader and the equivalent of at least one FTE from the following roles: special educator/early childhood educator, occupational therapist, physical therapist, speech-language pathologist, service coordinator (in a dedicated SC model). All roles must be represented.

Strategies for Establishing a Team Team members may also include: dietitian, nurse, orientation and mobility specialist, teachers of children with vision or hearing impairments, psychologist, social worker.

Strategies for Establishing a Team Team Load (number of families) Dedicated service coordination model: Service coordinators = 3 @ 30-35 per SC ECSE, OT, PT, SLP = 25 families per discipline per FTE (full-time equivalent position) Blended service coordination role: ECSE, OT, PT, SLP = 15 families per discipline per FTE (minimum)

Strategies for Establishing a Team Determine distribution of eligible families across catchment area Identify the area the team is to cover (i.e., counties, zip codes, school districts) based on family distribution Determine the number of teams necessary to cover the catchment area Assign available practitioners to teams beginning with those who can give the most time to the program Develop mechanism to pay for team meeting time

Moving to a Primary Coach Approach Two opportunities: Newly referred children and families 2. Currently served children and families

Newly Referred Children: 1. During the initial conversation with family members and care providers identify activity settings, child interests, and family priorities in order to determine the expertise necessary for the assessment. 2. Conduct assessment across activity settings to identify the supports necessary to promote the child’s participation.

Newly Referred Children: 3. Develop functional, discipline-free participation-based IFSP outcomes to reflect child’s interests and care providers’ priorities. 4. Select primary coach and determine frequency, intensity, and duration of supports based on the best match between coach and learner expertise availability of necessary coaching to achieve IFSP outcomes as quickly as possible.

Currently Served Children: Identify families who have expressed interest in this type of an approach or frustration with having multiple practitioners. Review all team members’ caseloads to identify overlaps among other families in the area. Select a few children who have the most overlaps and discuss with care providers implementing the new approach for a trial period.

Currently Served Children: 4. Conduct an IFSP review to ensure the outcomes are participation-based discipline-free functional/contextualized (i.e., not impairment oriented), and based on care providers’ priorities and child’s interests.

Currently Served Children: 5. Select primary coach and determine frequency, intensity, and duration of supports based on the best match between coach and learner expertise availability of necessary coaching to achieve IFSP outcomes as quickly as possible.

Implementation Data Matched Sample Study (Shelden & Rush, 2006) Experimental design 21 matched pairs Controls were child age at entry into study, child diagnosis, length of time served by program, simultaneous participation in program, family SES Diagnoses included: developmental delay, seizure disorder, cerebral palsy, Down syndrome, visual impairment, severe disabilities, autism/PDD Shelden & Rush, in preparation

Implementation Data Matched Sample Study cont. Mean age at entry Experimental: 11.9 months Control: 12.4 months Mean age at exit Experimental: 19.7 months Control: 21.9 months Data collected: (both groups) all developmental testing, IFSPs, actual billed units for all IFSP services, (experimental group only) team meeting minutes, team meeting time by child per team member, documentation of joint visits, coaching logs Shelden & Rush, in preparation

Implementation Data Matched Sample Study cont. Results Experimental group had significantly fewer service hours including team meeting time than control group IFSP outcomes were met more often by children in experimental group IFSP outcomes were more participation based and care provider focused for children in the experimental group Shelden & Rush, in preparation

Implementation Data Matched Sample Study cont. Results No differences noted between the experimental and control group for child developmental outcome data Early intervention services and supports provided using the evidence-based practice model were significantly less expensive and of higher quality as defined by current research than those services provided outside of this model Shelden & Rush, in preparation

What Happens From clinic-based, segregated, decontextualized environments to natural learning environments From no teams to dedicated regional teams From no regular contact among practitioners to weekly team meetings, joint visits, and ongoing interactions (i.e., phone calls, email) From limited insight and speculation to actual administrative knowledge of practices occurring during visits

What Happens From individual practitioner responsibility for use of evidence-based practices to team and program accountability From limited services to access to a full team of practitioners from a variety of disciplines From hierarchical view of roles to equality among team members

What We Know Team Meetings Teams that meet weekly learn and implement the practices Teams that meet weekly have higher accountability among team members Teams meet on average less than 1 ½ hours per week When coaching occurs at team meetings, the practices are implemented Meetings are more productive when guided by a competent, consistent facilitator All team members attend the team meetings The order in which items occur on the agenda matters Dedicated service coordinators love team meetings

What We Know Early Intervention Process Joint Visits Same team should support families from initial referral through transition Joint Visits 15-20% of total visits are joint visits Disciplines other than core, may require more joint visits Three steps are required for joint visits to be effective Changes in Primary Coach Primary coaches do not change frequently

What We Know Time Leadership Service Coordination Moving to a primary coach approach takes intensive support over time Leadership Administrative support for use of the approach is essential Program administrators must attend at least some team meetings Service Coordination Primary coach works with any time of service coordination model

What We Are Learning Team load Frequency and duration of team meetings Amount of time spent in team meetings per practitioner per child How to decrease the amount of time required to learn and implement the practices Comparison in cost of primary coach approach and traditional model Outcomes for families Outcomes for children

Family Feedback “I sought and I found the perfect program for my daughter. There was no hit and miss. I am very pleased that my first program for my daughter was ___ because this team that was sent to us comes second to none. My team has given our family so much, much more than I ever expected.”

Family Feedback “I love working with my team!” “This is a wonderful program. Because of participation in the pilot program, my child is now able to tell us what he wants rather than pointing.” “Our son has grown more rapidly as a result of our involvement.” “The program has helped my daughter and also helped myself and her father.”

Family Feedback “A team leader and sole service provider has been sufficient in meeting the needs of our son. The team leader/coach has been willing to consult with other therapists and then report back to us. She has been knowledgeable and skilled in the areas of need.”

Family Feedback “July 5th will surely be a sad day in our house…the team will be gone, but not the wonderful teaching tools, advice, and early intervention knowledge that they have shared with us throughout our time together. My team deserves much recognition (and a really big raise….☺) for helping us to bring (child’s name) back to us. We love our team!”

Family Feedback “My family has been very pleased with the service we have been receiving on behalf of our daughter. Our service provider has presented herself to be very professional and extremely knowledgeable. Whenever we have questions pertaining to other areas of therapy, our service provider never fails to consult with the team and return with an answer. We are very pleased with the coaching method and are pleased to say it is working extremely well for our family. Thank you.”

Family Feedback “I have a foundation to build on that the team has helped to establish in order for us to work towards even more improvements with (my child), and every goal we had set has been matched to great satisfaction. I have no questions or concerns at this point, just some well deserved words of praise to my team for helping me to find my baby girl in the dark hole that held her prisoner.”

Questions & Discussion

References Bell, S.T. (2004). Setting the stage for effective teams: A meta-analysis of team design variables and team effectiveness. Unpublished doctoral dissertation, Texas A & M University, College Station, Tx. Dunst, C. J. (2000). Revisiting "Rethinking early intervention." Topics in Early Childhood Special Education, 20, 95-104. Flowers, N., Mertens, S.B., & Mulhall, P. (1999). The impact of teaming: Five research-based outcomes of teaming. Middle School Journal, 31(1), 57-60. Larsson, M. (2000). Organising habilitation services: Team structures and family participation. Child: Care, Health & Development, 26, 501-514.