Session 8Alabama Routines-Based Home Visit Bootcamp

2021 Summer EveningsDr. Robin McWilliam

Outline

1. Review homework2. Parenting basics3. Joint visits4. Incidental teaching5. Modeling6. CC2CC7. Next steps in approval

Review Homework• Write 250 words, reflecting on this course of 7 sessions, so far, on Routines-Based Home VisitingNew ways of thinkingReassurancesThings you disagree withMost important, any changes you've made or will make

• Due in 1 week (July 26)• ramcwilliam@ua.edu

• One part that I have difficulty with is that I am a new pediatric physical therapist and am also very young. I am not married and do not yet have kids. It is difficult to embrace the technique of asking the parents if they have any ideas or suggestions four times before giving advice because the parents sometimes already think that I am not sure that I am qualified or experienced enough, so if I ask them what they think, they might believe that I do not know what I am doing. I also believe that we are there because they need suggestions. If they were able to come up with it on their own, we wouldn't be there.

Experienced person new to EI• To this day I (XX) still heavily rely on my fellow coworkers in the XX and XX

fields to provide input into my treatment sessions to provide the best therapeutic care for all of my children. Even then Im sure I will have ideas that I learn years from now and wish I could have utilized them with a previously targeted child. So to say that EI will only use one therapist to treat a child holistically for all their targeted areas is personally offensive to me as a specialized therapist. Several of your best EI therapist are so good at their jobs because they have many years of experience in the world of outpatient or by working side by side for other therapist in other fields. This collective knowledge takes years of experience and can not be capitalized through a quick conversation to grab an idea from another therapist. It requires observation, intake of information (which you hard core push), and multiple ideas attempted until you find the best fit for the child and their caregivers. Its upsetting to think that someone can have a quick conversation and portray the same knowledge that I worked so hard to obtain over the many years of my schooling and through pediatric service.

• some families are frustrated with wanting more direct therapy for their child

• I realized quickly how often I have come into the home and worked directly with the child demonstrating to parents how to play with their children and make it a fun “learning activity,” but it was me doing all of the work. That has been a challenging shift for me. It is also a challenge to get the parents to direct our sessions and take a more leadership role.

• There are things that the state office has provided guidance on which differ from the information received during the sessions. For consistency and continuity, it is imperative that all should be on one accord before information is presented because if not it does provide some level of confusion as to what should be done and how.

• A concern or challenge is that families expect more hands-on intervention. I believe most families expect a session at home to look like a session in an outpatient clinic.

• the professional opinion of an educator is not always valued as much as I feel it should be…. . I understand that we are to give suggestions to families, but sometimes I feel like when I ask too many questions about if a suggestion will work, then it appears that I am unsure if it will even work myself.

• As a “seasoned” occupational therapist working in the clinical profession for 24 years, I thought I had a clear understanding of my role in providing services to children in EI. This was until I participated in the summer RBHV training sessions. The last seven weeks, I have learned that I was doing early intervention mostly all wrong. The training has opened my eyes to asking questions before suggesting, being a facilitator not a dictator, and most of all, respecting that the parent knows their child better. My job is to build the caregiver’s capacity within their own lives.

• By investing in the parent’s concerns and asking questions to obtain a better understanding overall, I can provide better services to the family. This will result in better child outcomes than that of structured clinical treatments. This training has also taught me how to focus the documentation on the parent’s agenda. Although this has been a challenge for me to provide simple concise documentation, I understand the importance of the NSF being for the family first. The training has changed my entire outlook of providing services to not only EI clients but in other OT practices. I am more relaxed and confident with talking to the caregivers regarding their goals and concerns happening within their time schedules.

• The Routine Based Home Visit model makes my job so rewarding now. I love that I get to build relationships, strengthen caregiver’s capacity, and mostly promote the child’s independence within their daily routines of life.

• The Routines-Based Home Visit training course could not have come at a better time in my career. While in occupational therapy school, we very rarely discussed early intervention in depth. We discussed the basic information regarding early intervention practice such as the differences between early intervention services, outpatient pediatric services, and school-based services. Therefore, the extent of my knowledge was the requirement of an IFSP and that the main focus during visits was on the family as a whole rather than directly on the child.

• Considering that [name of agency] is my first job out of OT school, I was concerned about how to structure visits, being completely on my own, and all the other ins and outs that I did not know about. I was thankful to get into the RBHV trainings before I began building a caseload so the kids and their families would be able to get the most out of our visits. Early intervention has been a learn as I go process, but I am thankful for the guidance from the RBHV training. The last seven trainings have taught me new ways of approaching the families on my caseload. They’ve taught me efficient techniques in allowing the families to determine the direction of the visits. It was a major adjustment for me when I was told that EI visits were not about the child alone, and that I may not even “do interventions” with the child while at the visits. However, Dr. McWilliam has done a great job in giving real life scenarios/examples to guide me in how to provide effective OT services in EI. One of the main things I have learned during the RBHV trainings is the importance of the family’s functional capabilities in every day life, not just the child’s functional capacity. These trainings have reiterated that a child truly cannot be fully functional when their family and their environment are not functional.

• I have gained reassurance throughout the last seven trainings, and they have made me more confident in my visits. I will continue to develop my note taking skills using the NSF and matrices. All in all, thank you Dr. McWilliam, for teaching me, for increasing my knowledge, and for instilling confidence in me during this new phase in my life and my career.

4 Parenting BasicsIn the RBM

Talking

Hart & Risley(1995). Meaningful differences in the language learning environments of young children.

Talking to Children

• Hart & Risley (1995). Meaningful Differences.

• 30-million word gap

Double Whammy!

EIEIO 16

Reading

Nicole Beurkens

Reading With Children

Starting when? Reading?

Playing (Being Playful)

Teaching

Teaching Children

Reinforcement principles

Prompting

Types

Levels

Timing

Fading

Prompts

Reinforcers

Shaping

4 Parenting Basics in the RBM

•Talking•Reading•Playing•Teaching

Joint VisitsThe ultimate in teamwork with the PSP approach

Joint Visit Poll

•What I'm still not totally confident about is/are (multiple choice)• The PSP's responsibilities on the joint visit• The second team member's (STM's) responsibilities on the joint visit

• The family's role on the joint visit• The three reasons STMs might interact with the child

Supporting Colleagues on RBM Implementation• Visits Joint visits ("consults") are different from regular RBHVs Consult the Joint-Visit Checklist

In either PSP or STM role, model key practices from RBHVs and CC2CCHoosiers Rule Opportunities for 3 actions Feasibility question Commitment to implement (right side of NSF) This is really the role of the PSP

Panel on PSP

PSP's Responsibilities

Preparation1. Tell caregiver you have a colleague/friend who

knows much about this issue (versus let's get a therapist)

2. Schedule a joint visit3. Ensure caregiver and second team member (STM)

are clear about why we need the joint visit1. Address one or more particular interventions2. Check up

PSP's Responsibilities

1. Introduce the second team member (STM) to the caregiver

2. Ask the caregivers if they had any additional information they wanted from the STM

3. Use active listening with the STM, to ensure everyone understands the information

4. Avoid checking in with the caregiver in a condescending manner (e.g., “Do you understand what she’s saying?”)

PSP's Responsibilities5. Ensure the STM’s information was applied to

routines6. Ensure the caregiver had a chance to discuss how

promising the suggested intervention was (reflect on whether it is likely to work)

7. Ensure the caregiver had a chance to discuss how feasible the suggested intervention was (reflect again)

8. Near the end of the visit, ask the caregivers if they wanted any more information from the STM

PSP's Responsibilities Not on Checklist•Document the visit on the Next-Steps Form

• Make explicit you worked with the STM and what that person's service was (e.g., "Joan [PT] showed Merida (mother) how to support Bro when he pulled to standing"; "Joan [PT], Merida (mother), and I discussed how often Joan should check in on Bro's motor goals. We decided every 2 months."

• If the visit resulted in interventions the caregiver intended trying right away, record those on the right-hand panel.

Second Team Member's Responsibilities9. Explain what his or her role/area of expertise

was10.Address the items the PSP and the caregiver

said they wanted information about11.If hands-on interaction with the child was

needed for assessment, explain to the caregiver what he or she was doing?

12.As part of assessment, ask the caregiver what the child typically did

STM's Responsibilities

13.Discuss child functioning in routines14.Ask the caregiver to show what the child could do

or what the adults did to help/teach the child15.Ask the caregivers if they wanted a demonstration,

before demonstrating16.Explain what he or she was doing, while

demonstrating17.Ask the caregivers if they wanted to practice the

intervention right then

STM's Responsibilities

18.In response to the caregiver’s trying the intervention, be encouraging

19.Talk up the PSP (e.g., “You have a great home visitor. She’s really knowledgeable. She has helped a lot of families. She can help you in the coming weeks with this strategy.”)

Both Team Members' Responsibilities20.Agree on how they would determine the

need for follow-up consultation, including possibly a joint visit

21.Agree on follow-up communication about these interventions

Next Steps: Brandi