You have accessThe ASHA LeaderFeature1 Mar 2020Giving Families a Go-To TherapistWhat does the rise of the primary service provider approach in early intervention mean for speech-language pathologists? Possibly a chance to enhance services—if implemented as intended. Dathan RushEdD, CCC-SLP Dathan Rush Google Scholar , EdD, CCC-SLP https://doi.org/10.1044/leader.FTR1.25032020.44 SectionsAboutPDF ToolsAdd to favorites ShareFacebookTwitterLinked In When I first heard about it 30 years ago, it seemed blasphemous. I sat listening, horrified, as a conference presenter extolled the virtues of a transdisciplinary model of service delivery in early intervention. I sensed similar distress in the audience, which included speech-language pathologists and clinicians from other disciplines. The lecture hall had tiered seating like the Colosseum in Rome, so we surrounded and looked down on the presenter. Much like Caesar, we were ready to send in the lions to remove this therapist traitor, as she seemingly instructed us to surrender our Certificates of Clinical Competence and spurn our licensure laws. Was she really suggesting that we all become "unitherapists"—created to meet all the needs of any child enrolled in the early-intervention program? I decided out of either fear or intrigue to listen to her plea. She did make some good points about working with caregivers of infants and toddlers with disabilities, and she had clearly done her homework on evidence-based early-intervention (EI) practices and the law. "Why would this be happening?" I thought to myself. "And if it's going to happen, how will we ethically do it without training someone else or being trained to do something outside our scope of practice?" As it turns out, this transdisciplinary model was not a new idea. It has been around since before EI's inception in the 1980s, offering the appeal of streamlining supports through use of a primary service provider (PSP) who works most closely with the family. According to the Early Childhood Technical Assistance (ECTA) Center, the model's use has grown over the years. Meanwhile, it has undergone a change in nomenclature, shifting in most descriptions from transdisciplinary model to PSP approach, with a refined definition: A teaming process in EI whereby one member of a multidisciplinary team is selected as the PSP, with other team members supporting as needed. The PSP works closely with the child's caregivers, using a capacity-building coaching interaction style to help them use everyday learning opportunities to promote child development. Shifts in favor of harnessing such everyday learning opportunities by providing EI services in children's homes, communities, and child care settings have led to wider acceptance of the PSP approach. But this rise has also spurred questions like the ones I initially had—regarding its efficacy and ethicality, requirements for interprofessional collaboration, and potential scope of practice issues. So, what are the overall pros and cons? And can we make it work better? Let's dig into it. Rise of the PSP approach What is it, exactly, that causes the resistance to a PSP approach that I saw at the lecture I attended? It's the notion of one team member performing a clinical task that is traditionally implemented by a provider from a different discipline, giving rise to concerns about work outside one's scope of practice and violation of licensure laws. This approach is, however, perfectly legal under the Individuals With Disabilities Education Act (IDEA) when used appropriately. IDEA requires that eligible children and their families have access to a team of professionals from a variety of disciplines. The three common models identified in the teaming literature are multidisciplinary, interdisciplinary, and transdisciplinary (see sources). These models vary based on levels of team interaction and parent involvement, and approaches to assessment and intervention. The shift from multidisciplinary and interdisciplinary teaming models to transdisciplinary and now PSP over the past 30 years has been driven by two factors. First, IDEA Part C requires that services be provided in the child's "natural environment" (such as home, community locations, and child care program) because young children learn in the context of everyday activities with the important people in their lives (see sources). Second, a child's learning is not restricted to when the EI practitioner is present. The practitioner's role, therefore, is to help caregivers know how to promote the child's participation and development during everyday natural learning opportunities, such as mealtime, diaper changes, and dressing. The PSP's focus is on the caregiver, not on conducting traditional block practice drills, exercises, and activities with the child. Instead the provider teaches caregivers strategies they can use, such as following the child's lead or modeling words. The PSP bases the time and frequency of visits on when these activities naturally occur and how much support the caregiver needs from the PSP. PSP pros Pro: Every family gets a team Under IDEA Part C, the PSP approach provides caregivers with access to an EI team. The team minimally includes an early childhood special educator (ECSE), occupational therapist (OT), physical therapist (PT), SLP, and service coordinator (SC). The team may also include an audiologist, nurse, nutritionist, behavior specialist, social worker, psychologist, and others, depending on the child's disability. Members of the EI team, along with the family, develop an Individualized Family Service Plan (IFSP) that includes participation-based child learning outcomes and the supports necessary to help the caregivers achieve the outcomes. Based on information from the family, referral sources, evaluation and assessment results, and the IFSP outcomes, the team moves through a systematic process for identifying one member (the PSP) who would be the best match to potentially support the child and family from the point of the initial IFSP until the child transitions to another program at age 3. For guidance on selecting a PSP, including identifying and working through role gaps and overlaps, teams can use a worksheet from the Center for the Advanced Study of Excellence in Early Childhood and Family Support Practices. The team process helps to decrease potential gaps and eliminate duplication in services. The PSP is responsible to the rest of the team and family for helping to achieve the IFSP outcomes. Rather than have two or three team members working with the family on mealtimes, the family has one PSP through which to access other team members as needed. One way for the PSP to access other team members' expertise is via a required—usually weekly—meeting of the full EI team. In addition to this, the full team meets with the family regularly to ensure progress toward IFSP outcomes. A tool in "The Early Intervention Teaming Handbook" provides guidance on scheduling. Regular meetings provide opportunities for collaboration among team members and help ensure the team addresses issues. If team members determine the family needs direct access to the knowledge of another discipline, a joint visit to the family may be scheduled. For example, let's say the team chooses the SLP to serve as PSP for a child with Down syndrome. The SLP sees that the child likely needs an insert for his high chair to fully participate in the family mealtimes. At the weekly team meeting, the SLP calls on the PT to assess the situation, so the PT visits the family with the SLP at mealtime. The PT's role is not to teach the SLP to construct the seat insert—because that expertise is the PT's. As the PSP, the SLP's role is to know when to call in such expertise. If, on the other hand, the ECSE had been selected as the PSP, then the ECSE would likely ask the SLP to provide strategies to promote language development during mealtime routines. The SLP could accomplish this during a series of joint visits to educate the ECSE and parent on using the strategies and knowing when to bring in the SLP again, as needed. Pro: Every family has a PSP Multiple providers interacting with a family can result in confusion, increased parental stress, and unmet needs. The more providers working with the family, the less helpful the services can be, due to conflicting intervention approaches, recommendations, and expectations. A PSP can provide consistency across settings and may be positioned to build a trusting, long-term relationship with the family and other caregivers. The PSP can come to know the child and caregivers, how they learn, and which everyday activities can best promote the child's development (see sources). The family knows they have a team and trusts that the PSP will access support of other team members when necessary. Pro: Every team should have an SLP ASHA's Practice Portal on Early Intervention indicates that SLPs may be qualified to serve as the PSP and support another discipline as PSP for certain infants and toddlers. SLPs would neither provide a service outside their scope of practice, nor teach another team member to implement an intervention outside that professional's scope. When a highly specialized skill or intervention technique is required for example, making an orthotic, selecting and programming an augmentative communication device, or transitioning a child from g-tube to oral feedings) only team members with the required skills should provide the service. When a PSP approach is implemented within these parameters, the SLP is practicing within ASHA guidelines and state licensure laws. PSP cons Now let's consider some potential challenges of using a PSP approach in EI. Con: Every local EI program may not have a team A PSP approach requires dedicated teams serving specific geographic areas with members who know one another's strengths and can identify when they need support. Local EI programs that do not have ongoing access to, minimally, an ECSE, OT, PT, SLP, and SC cannot use a PSP approach with fidelity. If team members lack the availability to serve as a PSP, attend regularly scheduled team meetings, and participate in joint visits, a PSP approach will not work. Con: Additional requirements of team members It is true that providers serving on a PSP team must possess knowledge beyond their specialty—in the areas of, for example, typical child development across multiple domains and basic parenting supports for toilet training, sleep strategies, and community resource identification. They also should be skilled in building adults' capacity to promote child learning in their everyday activities. A PSP team requires ongoing in-service training to build shared knowledge, promote mutual accountability, and ensure use of evidence-based EI practices. To be effective and coordinated, and to eliminate potential gaps, the team will need to make extra time in already busy schedules for team meetings, joint visits, and other shared work. Con: Misperceptions about PSP use Another potential barrier to adoption of the PSP approach is misunderstanding—similar to what I experienced when I first heard about it. The way I first perceived it was inconsistent with how I came to understand it as a properly implemented approach. People may reject the approach because they misperceive that it means: Less service. Some may assume that, with a switch to a PSP, a family that traditionally would receive multiple services several times a week now would receive just one service once a week. However, the PSP should support the family as frequently as necessary, depending on the family's typical activities. The PSP team needs to base decisions about frequency and intensity of service on the amount of support the PSP and family determine as needed and helpful. Watered-down service. Some express concern that with a PSP, caregivers can access only one team member's expertise, practitioners are reduced to "generalists," and some team members may be excluded. To the contrary, with a PSP approach, caregivers may still access all team members' discipline-specific expertise. The key is to introduce that expertise as needed. For example, an SLP might help an OT/PSP boost a child's bathtime learning and participation by bringing in high-frequency, developmentally appropriate words the family can use in this context. Unable to bill for service. EI practitioners may worry that, as PSPs, they won't receive third-party reimbursement for services. In reality, team members may bill for their services in accordance with what is allowable for them as a provider. Similar to other teaming models, meeting time, joint visits, and parts of a particular visit may not be reimbursable by public and private insurers. That means state and local EI programs must identify other funds to pay for this non-billable time. How to help PSP work better The PSP approach is comparable to any other EI practice in the sense that its effectiveness depends on each team member working at making it work. Here are some specific actions you can take to help: Show what you know. Ensure other members of your team know about your knowledge and skills that would make you an excellent choice to serve as PSP for a specific child and family or to support another team member serving as PSP. Share what you know. As SLPs, we have information that we want everyone to know—such as how to promote basic language development, the importance of hearing screening, the problems associated with putting a baby to bed with a bottle. Make sure your team members have this basic knowledge and can share it with others. Also ensure you share when you need to be directly involved with the child and family. Learn from others. Hone your ability to recognize when you and a family could benefit from other team members' expertise. Learn basic information from other disciplines that all EI providers and caregivers should know, such as simple positioning techniques, low-tech assistive technology, and positive behavior supports. Ask for support. Never hesitate to request assistance from or bring questions to other team members at the next team meeting. That's what the team is there for. Returning to those initial PSP concerns I experienced 30 years back, I've since put them to rest as I learned more about the model and have seen it in action. Misperceptions about PSP are often based on hearing it described inaccurately or seeing it used incorrectly. As SLPs working in EI, we must know the implementation conditions necessary to make PSP work right—and to best help the child and family. Doing so will minimize the cons, maximize the pros, and ensure that every child and family receives the support they need. Sources Division for Early Childhood (DEC). (2014). DEC recommended practices in early intervention/early childhood special education 2014. Retrieved from http://www.dec-sped.org/recommendedpractices Google Scholar Early Childhood Technical Assistance Center (ECTA). (2014). EI service delivery approaches/models. Retrieved from: https://ectacenter.org/topics/eiservices/approaches-models.asp Google Scholar Rush, D. D., & Shelden, M. L. (2012). Worksheet for selecting the most likely primary service provider. CASEtools, 6(3), 1–9. Retrieved from: https://fipp.org/static/media/uploads/casetools/casetool_vol6_no3.pdf Google Scholar Shelden, M. L., & Rush, D. D. (2010). A primary-coach approach to teaming and supporting caregivers in early childhood intervention. In R., McWilliam (Ed.), Working with caregivers of young children with special needs. New York, NY: Guilford Press. Google Scholar Shelden, M. L., & Rush, D. D. (2013). The early intervention teaming handbook. Baltimore, MD: Paul H. Brookes. Google Scholar Workgroup on Principles and Practices in Natural Environments, OSEP TA Community of Practice: Part C Settings. (2008 March). Agreed upon mission and key principles for providing early intervention services in natural environments. Retrieved from http://ectacenter.org/~pdfs/topics/caregivers/Finalmissionandprinciples3_11_08.pdf Google Scholar Workgroup on Principles and Practices in Natural Environments, OSEP TA Community of Practice: Part C Settings. (2008 March). Seven key principles: Looks like/doesn't look like. Retrieved from http://www.ectacenter.org/~pdfs/topics/caregivers/Principles_LooksLike_DoesntLookLike3_11_08.pdf Google Scholar Author Notes Dathan Rush, EdD, CCC-SLP, is director of the Family, Infant & Preschool Program at the J. Iverson Riddle Developmental Center, North Carolina Department of Health and Human Services, in Morganton, North Carolina. [email protected] Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 25Issue 2March 2020 Get Permissions Add to your Mendeley library History Published in print: Feb 28, 2020 Metrics Downloaded 3,115 times Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2020 American Speech-Language-Hearing AssociationLoading ...

Giving Families a Go-To Therapist

ivySCI AI Smartly Parses PDF, Answers Researchers' Questions, and Helps You Understand Papers in Seconds

Journal Info