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ECI: Making It Work - Service Delivery

5. Service Delivery

5.1 Moving on to service delivery

Notes:

MIW SC:

After the IFSP is signed, we can begin delivering services.

Note that this training does not address specific clinical techniques for services to children and their families. You bring the knowledge, training and experience of your profession to the services you will provide to individual families. This module does address the components of service delivery common to all ECI services.

The ECI approach to service delivery

5.2 Activity: Routines based approach, video

Notes:

During the IFSP, lots of information was gathered about how the child functions in daily routines and activities. Understanding the routines of a family will allow you to effectively work with and coach the family so they can enhance n their child’s learning and development. Routines-based intervention is different than traditional therapies and services. This 7 minute video will introduce you to the approach.

(Early Intervention - A Routines Based Approach: What Early Intervention Can (And Should) Look Like. Video produced by the Integrative Training Collaborative of Virginia.) The video is linked here: .

5.3 Self-check on video

Which concepts were presented in the video?

A. Intervention is a shared responsibility between the provider and parent

B. Increasing parent confidence and competence

C. Coaching

D. Routines-based intervention

E. Individualizing services based on family needs, priorities and preferred activities

F. Increased intervention opportunities

G. Strategies to help the parent practice activities when the provider is not present

The correct answer is all of the above..

The video you just watched addressed all these concepts and emphasized the importance of a routines-based approach when providing ECI services. This approach is a shift from the clinical model and stresses the importance of valuing the priorities and uniqueness of the children and families we serve.

You will learn more about the routines-based approach throughout this section of the module ...

5.4 Natural environment

Notes:

IDEA Part C requires that services to infants and toddlers and their families be provided in natural environments, to the maximum extent appropriate. IDEA Part C defines Natural Environments as settings that are natural or typical for a same-aged infant or toddler without a disability, and may include the home or community settings. But the natural environment for a child is more than just a place. It includes the daily activities of the child and family, and parents’ perceptions and beliefs based on their culture.

Question: What percentages of Texas ECI Services are provided in the family’s home or in a community setting? What do you think?

A. 30%

B. 50%

C. 90%

D. Over 99%

The correct answer is D.

In Texas, over 99% of ECI services are provided in the family's home or in community settings where children without special needs might also be, such as a daycare, park, or even mall or restaurant.

In very limited cases, a service cannot take place in a natural environment due to the child's health or another special circumstance. For services provided in an office, a clinic, or other settings not natural for most children and families, the reason must be documented in the child's IFSP.

View the following video if you’d like to see an example of what service delivery looks like in a child care setting. The video is called Evan’s Story. You will start watching the video at 4:41. Otherwise, continue on within the module.

The video is linked here: .

5.5 Timely services

Notes:

Federal regulations also require that every service planned on the IFSP must begin in a timely manner. ECI defines “timely” as within 28 days from the date the IFSP is signed by the parents. ECI programs must also make reasonable efforts to provide flexible hours for service delivery so parents can participate. This means occasionally you may need to see families outside of regular business hours.

5.6 Child development

Notes:

Knowledge of typical child development is crucial to your work in ECI. A firm foundation in child development is essential to evaluate and assess a child’s abilities, to plan outcomes, and to assess ongoing progress. Knowledge of developmental milestones is necessary when talking with parents about what we are working on and what comes next. Most professional disciplines in ECI received a foundation of child development during their education and professional training. Keep in mind that influences on child development can vary according to cultural context. If you feel that you need to improve your knowledge of typical child development, there are numerous resources available, some of which are located in the library. You can also view resources on the MIW Bookshelf regarding child development. The MIW Bookshelf is located in Section 1.

5.7 Whole child

Notes:

All early intervention services must address the whole child within the contexts of the family and natural learning activities. Infants and toddlers develop simultaneously across all domains, and development in one area is generally impacted by other areas. This means, regardless of your discipline, your knowledge as a provider must cross domains, and you will consider all developmental domains when delivering any service. This requirement also means the activities, priorities, and interests of the family must be taken into account when a service is delivered. Your services should be focused on activities that regularly occur for the family such as mealtime, shopping for groceries, driving to daycare, or playing with siblings.

Remember that the five domains are: Adaptive, Communication, Motor, Cognitive and Personal-Social.

5.8 Activities crossing multiple domains

MIW SC:

Let's look at how one activity can cross many developmental domains at a time. Let’s look at each of the children to learn more ...

Andre at snack time: Andre is sitting at the kitchen table with his foster siblings while his mom, Lydia makes a snack. Lydia asks Andre and his foster siblings questions about their preferences for snack, as taught by Andre’s EIS. Mom engages Andre and his siblings in reciprocal conversation which builds on Andre’s language skills, cognitive skills and strengthens his personal-social development. When Andre feeds himself his snack, he is also working on his adaptive skills. This activity is involving the following developmental domains: communication, cognitive, personal-social, and adaptive.

Elizabeth during “tummy time”:: Susie places Elizabeth on her tummy for “tummy time”, as recommended by her OT. While Elizabeth is on her tummy, Susie engages her in play. Susie props Elizabeth up using a rolled towel. This helps to make things more comfortable and easier for Elizabeth to look around and interact with her mom. Susie holds toys up for Elizabeth to look at and to get her to strengthen her back, arms and neck muscles. Susie laughs and smiles with Elizabeth during “tummy time.” During this activity, Elizabeth builds strength in her core muscles (gross motor), strengthens her personal-social development through smiling, laughing and bonding with Susie, and builds her language skills by listening to Susie talk and responding to her voice. This activity involves the domains of gross-motor, personal-social, and communication.

Riley during nightly routine: Riley’s parents, along with his ECI team, are working to assist Riley in developing boundaries, improve his language skills and to decrease his maladaptive, sensory seeking behaviors. Riley’s team has provided information to his parents about establishing a consistent, nightly routine for Riley, which involves bath time, sensory tasks and reading prior to bed. Riley’s nighttime routine addresses many of his developmental domains. Riley’s adaptive domain is addressed when he get undressed for his bath, helps with bathing, and assists with putting on his pajamas. He works on his language and cognitive skills during his nightly story time and when following directions during the routine. His social and emotional development is addressed by being actively engaged with his parents throughout routine. This activity involves the adaptive, communication, cognitive, and personal-social domains.

5.9 ECI services are unique

Notes:

Let’s consider how the ECI service delivery model is different from other therapy, or early care and education providers.

ECI services focus on the ability of the parents or caregiver to impact the child. Your role is not only to provide direct intervention to the child; you will coach, teach, and support caregivers as they help their child grow and develop. Services are individualized based on the unique needs of the child and family and are intended to help parents implement activities that support their child’s development. ECI services are designed so the intervention continues when you are not present.

5.10 Importance of the relationship

Notes:

Brain research shows early learning occurs within the context of a relationship. The closest relationship most young children have is with their parents, and they will learn best by interacting with their parents rather than with a professional service provider. You should be sure your services support, rather than interfere with, the parent-child relationship. Having a child who is not developing like the other children can be an overwhelming experience. The family may be anxious, frustrated, or emotionally distant. If a professional appears to “rescue” the child or parent can interfere with the parent-child relationship. Your goal is always to enhance that relationship.

If you're interested, there's an article in the Professional Development section of the MIW bookshelf on how to avoid being a hero in service delivery. And instead, how to best empower the family. The link for the article is here:

5.11 Activity: How ECI services are unique

Notes:

MIW SC:

It's important to be able to describe to families how ECI services are different. Consider this situation: On your second visit to a family, the dad expresses concern by saying “we just seemed to spend the last session playing with him. When are we going to start working on his goals?” How would you respond? Jot down your thoughts before advancing to 5.12 to check your ideas...

5.12 What did you think of for your response?

Notes:

What did you think of for your response? What did you plan for your response to the concerned father? Select all that apply.

A. Explain that children learn through play

B. Explain that you will help the family find ways to practice skills needed to achieve outcomes through a variety of activities, including play

C. Tell the father that his daughter will learn best through family members and others who she spends the most time with, rather than a professional who visits a few times a month

D. Explain that intervention works best when skills are practiced throughout the day, every day

E. Ask the father how he would like to participate in the sessions, and how he thinks his daughter will learn best

F. Talk to the father about how each of the skills you are working on during play activities addresses the outcome

G. Provide this information verbally while demonstrating, and in a note when you leave so the father can do the activities before your next visit

H. Give examples of different activities in which the same skills can be practiced

I. Provide lots of opportunities for the father to practice during your sessions and give constructive feedback on the techniques he’s using

The correct answer is all of the options given.

All the suggestions in the list could be helpful in your response to the father.

This is actually a fairly common scenario, so take another look at the list and jot down any other ideas that might be helpful in this sort of conversation.

Components of Services

5.13 Components of Services

Notes:

The 7 Key Principles emphasize that infants and toddlers learn best through everyday experiences and interactions with familiar people in familiar contexts. Each time you provide a service, your goal will be to help the family incorporate intervention strategies and techniques into their daily routines and activities.

To make this happen, there are common components in every ECI service, no matter the discipline. These components are intervention techniques that have been shown in research to have the greatest effect on the learning and development of infants and toddlers, and should provide the structure for every ECI service you deliver, and are effectively accomplished by using a method called coaching, which we will cover later.

Take some time now to learn more about each of the four components, and think about how they apply to your professional discipline. ...

5.14 Service triad

Notes:

MIW SC:

The ECI team member, the caregiver and the child work as a triad. As a service provider in ECI, you won’t do much “hands on” intervention with the child. You will focus in every session on ways the parent can interact with their child to support the child’s development and participation in daily life. Here are examples about ways this can be done:

Examples:

• Demonstrate, Support, Give Feedback: You “model” how to support a child’s chin and lips while he sucks from a straw, then you hand the straw bottle to the parent to try. Give the parent support and feedback while he practices.

• Observe, Discuss, Try Out: You demonstrate gentle stretching to a child’s neck and shoulders. The parent watches, but she is afraid she will hurt him if she stretches him. You describe what it feels like, and you demonstrate again. You brainstorm with her how to distract him, and explain that his progress will be fast if she does the stretching every day. She is ready to try the return demonstration.

• Ask, Observe, Give Feedback: You ask the caregiver how she has been doing with the intervention since the last visit. The caregiver demonstrates how she has been supporting the child in sitting and provides some details on her successes and challenges with the intervention. You compliment her skill and tenacity, then offer some ideas on what she can do to address those challenges.

A child’s parent may request that you provide your services while the child is in the care of someone else, like a relative, a babysitter or a child care teacher. In these cases, the caregiver is part of the service triad, and we need to find ways to engage that person in the intervention. In a childcare center, you need to find ways to embed techniques in to the care activities to address the child’s outcomes.

When the parent will not present at each visit the team needs to communicate with the parent. Parents need to be updated on new strategies, involved in problem solving, and given the opportunity to ask questions, and to provide feedback on the child’s progress. It is important to include the parent as much as possible in services, even when the direct work occurs primarily with a caregiver other than the parent.

5.15 Addressing Routines

Notes:

MIW SC:

Another component of service delivery is identifying routines in which a family can implement strategies to help their child grow and develop. It is important to help caregivers learn to engage their child in enjoyable learning opportunities during daily routines because this will encourage more frequent practice of skills. Some families live chaotic lives, and it may seem hard to identify routines for learning, but they are there.

Examples:

• For a child who is learning to walk, look around the environment to help the parent see all the times and places he can practice walking - from the front door to the mailbox, from the crib to the kitchen in the morning and after nap, to the bathroom for bath, etc.

• To stimulate language, teach a parent to take a few seconds to name body parts and clothing at every diaper change.

• Suggest doing stretching exercises at every commercial break during one of the parent’s favorite TV shows.

• Brainstorm with a parent about when he can use techniques to help the baby roll over - every diaper change, when the baby wakes, or on the floor while siblings do homework. .

• Meet a parent at the grocery store to help her work on the child’s behaviors that are making trips to the store difficult.

5.16 Everyday materials

Notes:

MIW SC:

Another component of every ECI service is assisting families to use the objects, materials and toys they have access to in their home or community. If we bring toys into a home for a session and then remove them at the end, it is difficult for the caregiver to provide a similar learning opportunity when the visit is over. Bringing toys into the home can also infer some therapeutic “magic” in our materials. What kinds of objects and materials can be used during the visit? The possibilities are endless, and include anything you and the parent can imagine together.

• Cardboard boxes to sit in

• A laundry basket to support baby in the bathtub

• Plastic storage containers and rolled up socks or jar lids to practice putting in and taking out

• Photos and pictures from junk mail for naming objects

• Keys (that have been cleaned) to stimulate reaching and grasping

Activity Examples:

• You talk to a childcare provider about using single words to name the foods that are given to a child at meals and snacks.

• You and a parent brainstorm ideas for a child sit with his feet on a firm surface. A couch cushion or an overturned bin from the kitchen might work. Outside on the balcony, there is an empty overturned planter box that is just the right size and shape for sitting outside. The parent tries all of the positions while you provide feedback, demonstration and support.

• You help a parent make a book of pictures to look at with her child. You use a small plastic photo album the parent had in a drawer, and help the parent choose pictures from “junk” mail and magazines.

• You help the parent place selected clothing items in shoe boxes that the child can reach to work on receptive language and independent dressing skills.

5.17 Incorporating objects in home

Notes:

MIW SC:

There are so many things in a child’s home that can be used to provide services. Following are some suggestions of common items that can be used for working with children...

Pillow: You could show the parents how to use a pillow with Elizabeth for positioning, or make a fort and pretend play with Riley.

Blankets: You could show the parents how to roll the blanket to make a bolster for Elizabeth or sit Riley in it and use it as a swing for a sensory activity.

Ball: You could show Riley’s parents how to pass the ball back and forth with Riley for social interaction or used to practice words and sounds.

Container: You could show Elizabeth’s parents how to use the ball with her as a motivation to roll, reach and crawl.

You could put items in the container and take them out to practice labeling with Andre and Riley. It can also be used to practice words like “open”, “close”, “in”, “out.”

Clothes Basket: You could show the parents how to gather household items with Andre and Riley to work on receptive language and social interaction.

As Elizabeth meets her gross motor milestones, you could show her parents how to use a clothes basket as a walker.

5.18 Everyday materials article:

Notes:

Here are even more ideas about how to increase the use of everyday materials in your service delivery. Read the following article: {07D0901F-86B6-4CD0-B7A2-908BF5F49EB0}_59/increase_use_of_everyday_materials.pdf

5.19 Teaching Strategies to the Caregiver

Notes:

MIW SC:

Every time you go into a home to deliver a service, your goal is to help the caregiver learn and implement evidence-based strategies. As you work through a session, help the parent understand not only how to implement a strategy or activity, but how it will help the child meet the outcome, always remembering and emphasizing the primary learner during every ECI visit is the caregiver.

Here are some examples:

• You explain to the parent ways to play with playdough to help the child develop hand strength to hold a spoon for self-feeding.

• You teach a parent how to use single words and two word phrases when looking at a book with her child.

• You show a parent how to hold and carry a child in ways that will provide gentle stretching to his neck and shoulders.

• You suggest ways to put toys and other favorite items out of reach to encourage the child to ask for these items.

5.20 Components of Services (Wrap-Up)

Notes:

Now that you've learned more about the four components of service delivery, check your understanding...

5.21 Activity Components of Services

Notes:

Here’s how the four components of service delivery could apply to Andre.

Each of the following four questions describes a service. Which service is the correct answer to each description?

Question #1-Lydia explains that she bought two new puzzles for Andre. She says that he likes looking at and handling the pieces, but he loses interest quickly. EIS asks if Lydia will show her how they have been playing with the puzzles. Select the correct answer .

A. Teaching Strategies

B. Service Triad

C. Routines

D. Everyday Materials

The correct answer is B. Service Triad

Question #2: The EIS explains how to present Andre with one piece at a time, naming each piece. Lydia tries this, and says it works much better, and Andre places all 9 pieces in the puzzle with encouragement from Lydia. Select the correct answer.

A. Teaching Strategies

B. Service Triad

C. Routines

D. Everyday Materials

The correct answer is A. Teaching Strategies

Question #3- The EIS and Lydia look at the toy shelf in the den and identify the toys that are most appropriate for Andre’s interests and developmental level. Lydia decides that she will move to another room some of the puzzles and games that Andre isn’t quite ready for. Select the correct answer.

A. Teaching Strategies

B. Service Triad

C. Routines

D. Everyday Materials

The correct answer is D. Everyday Materials

Question # 4: You talk with the parent about times during the day that she can provide some supervision and interaction to Andre to play appropriately with toys. She says it is hard because of all the young children in the home. You look back at the routines that were described in his IFSP and together decide to work on activities for bath time and outdoor play in the backyard.

Select the correct answer.

A. Teaching Strategies

B. Service Triad

C. Routines

D. Everyday Materials

The correct answer is C. Routines

These four components of service delivery are interwoven into every interaction you have with families, so it is sometimes difficult to isolate the individual pieces from the whole of the work you do. Much of your work with families involves not just doing one thing at a time, but touching many components of intervention simultaneously. They can be effectively accomplished by using a technique called coaching. Let's look at coaching in more detail...

Coaching

5.22 Coaching

Notes:

The four components of ECI services are implemented through a technique called coaching, and it’s the best way to help parents learn the skills they need to enhance their child’s development. Coaching, rather than the direct provision of services to the child, allows caregivers to feel confident and competent by promoting their ability to:

• support the child in all areas of development.

• reflect on interactions with the child, and

• develop a plan for future interactions

There are five steps in the coaching process described by Barbara Hanft, Dathan Rush, and M'Lisa Shelden, therapists who are recognized as national experts in early intervention. The steps are joint planning, observation, action or practice, feedback, and reflection. Let’s learn more about these steps.

5.23 Joint planning

Notes:

MIW SC:

Joint planning happens at the beginning of every visit. Talk with the family about what has happened since the last visit. Here are some questions that can help guide the discussion:

• What techniques or activities has the family used since my last visit?

• What has worked well? ... then ask the parent to describe successes.

• What didn’t work well? ... then ask the parent to describe any challenges

• Did you notice any changes in your child? How did she respond to the techniques and activities? Do you think your child has made progress?

• Is anything causing worry or concern?

• Let’s talk about any changes related to the IFSP outcomes...

Based on the answers to these questions, help the family to decide what help you can provide in this visit. Do you need to?

1. Teach some new activities or strategies?

2. Adjust strategies that have been used?

3. Identify different routines for intervention?

4. Brainstorm different materials or toys in the home to use?

5.24 Cultural Considerations in Planning

Notes:

MIW SC:

Let’s consider how a family’s culture can effect joint planning. A speech pathologist became frustrated with a parent who would not join in a turn-taking activity on the floor, even after being asked directly and indirectly several times. The SLP later learned from a co-worker that in some Central American cultures, parents do not typically sit on the floor and play; that is the role of other children in the family, such as older siblings or cousins. Once the speech pathologist took culture into consideration, she adapted her intervention, using routines such as mealtime for the parents to practice turn-taking with their baby. She also showed the baby's older siblings games they could play with their brother.

5.25 Observation

Notes:

MIW SC:

Observation often happens at the same time as joint planning. This step involves observing both the parent and the child, because ECI services target both. Not only do we want the child to gain important developmental skills as a result of our services, we want the parent to feel increasingly confident and effective in his ability to develop and carry out strategies that will help his child. Click on both the mother and the child to see a couple of ways you can use observation:

1. Ask the caregiver to demonstrate what they have been doing with the child. You can then offer ideas and feedback about the techniques.

2. Watch the child as you talk with the parent. Point out any new skills, or subtle progress you see, and relate the progress to the work the parent has done since your last visit.

5.26 Action or practice

Notes:

MIW SC:

After planning and observing, you and the parent should be ready to try out some new ideas. This is when you will teach or adjust activities or strategies, help the parent practice for routines, and try out different materials or toys. This action and practice step will probably be the longest part of your service delivery visit. If you find you are completing the same activities with the family session after session, it’s probable the intervention is not having the desired effect. Return to joint planning to decide how you can modify your strategies, and consider asking other team members to provide input.

Modeling is one of the most common techniques used by service providers in the action and practice step. Effective modeling is more than showing a caregiver an activity. If you find yourself spending most of your time in a session working directly with the child, you probably aren’t using effective modeling.

Here are 8 steps for modeling, based on an approach suggested by Robin McWilliam:

1. Talk to the parent about a technique, and explain how it will help achieve the outcome.

2. Ask if he or she would like a demonstration. If the parent says yes, then ...

3. Tell the parent what you’re going to do.

4. Do it.

5. Tell the parent what you did and point out the consequence.

6. Encourage the parent to try it. The parent’s attempt is what we call “return demonstration”. This step is critical to the success of intervention and learning.

7. Watch the parent trying it.

8. Encourage the parent by finding some positives to point out. Give suggestions about how to modify, and provide corrective feedback as needed, in a supportive manner.

5.27 Activity: Action & Practice

Notes:

What if things stop at return demonstration because a parent doesn’t want to try?

Question: What would you do? What if the process stops at return demonstration because a parent is reluctant to try while you’re there? (select all that apply)

A. Emphasize that intervention in ECI happens between our visits.

B. Suggest that the parent can videotape the techniques and the service provider can view it with the parent at the next visit

C. Help the caregiver understand how a young child learns

D. Gradually move toward more parent participation in every session

E. Show the parent the activity many times, and show how much the child enjoys it

F. Continue to model, and hope the parent can do the activity when you leave

The correct answers are A, B, C, and D.

Those four strategies are good for encouraging parents to show you that they can implement activities when you aren’t there.

5.28 Feedback

Notes:

MIW SC:

Feedback is integrated all through the session. You provide feedback about the caregiver’s ideas during joint planning, about her observations of the child, and about her actions and practice.

Feedback can be used to provide acknowledgement, encouragement, and suggestions. Here are some varieties of feedback. Let’s look at some examples.

The following are examples of specific feedback.

1. Positive Feedback paired with suggestions for tweaks: That was great. I liked the way you supported her neck when you pulled her up to sitting. You might want to do it a tiny bit more slowly to help her work her muscles even more. Try it a few more times, and then let’s talk about the times of the day you can remember to practice.

2. Feedback to point out positive things you see in the parent-child relationship: He really responds to your voice. Look how quiet he gets when you talk to him.

3. Feedback to identify new routines: That is a really nice way to hold him for feeding he’s more upright and his legs are bent. You could also hold him that way when you show him a toy…

4. Feedback to explain why something was good: You supported her arm just enough so she was able to grasp the blocks and put them away.

5. Feedback to point out incremental skills the parent may not have picked up on: That was great! When he moved his hands together like that, he looked like he was starting to sign “book”

Consider videotaping the parent or caregiver practicing a skill while you coach. In today’s world, most everyone has a cell phone, and many of those phones have the capacity to record short video clips. The parent will have not only a visual reminder of the practice, but an audio reminder of your hints and instructions. Short videos can be a powerful teaching tool and can help caregivers who can’t attend your visit learn new strategies to use during times they spend with the child... Additionally, a parent who may be reluctant to practice during your session may be willing to make videos during the week for you to discuss in your next session.

5.28 Activity: Using video in early intervention

Notes:

MIW SC:

There are lots of ways you can use video to make your intervention more effective. This video clip illustrates one way a service provider could use video during a service delivery visit. The clip is located here:

Brainstorm at least three other ways video might support your work with the family. Record your ideas now and then discuss these ideas with your supervisor.

5.29 Reflection

Notes:

MIW SC:

This is the emotional component of feedback. Ask the parent how the activity felt for her and the child. Parents will not work on activities they don’t enjoy and won’t implement anything that causes them fear or worry so it is critical to have this discussion. If the parent does not feel comfortable, encourage him to practice a little more, or help him come up with some other strategies that might feel more comfortable. Ask the parent how he feels about the session you just completed, and then review the things you’ve covered that the family will work on before your next visit.

Reflection is also an opportunity for you, as a service provider, to think about your own work after a visit. Watch this short video clip about how a service provider uses video as a tool for the self-reflection process. Your self-reflection, combined with the family’s reflection about their child’s services is an important component of ongoing assessment and should inform planning for future visits.

This is the link for the video clip on reflection: .

5.30 Coaching (Wrap-Up)

Notes:

Good job! Now that you’ve look at each step in the coaching process, you’re ready to see what the coaching process looks like when you’re providing services to families.

Addressing Challenging Situations

5.31 Importance of knowledge and creativity

Notes:

Service delivery that emphasizes parent coaching and instruction takes a lot of creativity and requires depth of knowledge - we have to be able to:

1. adapt and respond during a session,

2. help parents find ways to imbed intervention into their daily routines and then adjust as necessary,

3. deal with the changeable nature of infants and toddlers- all of these require us as service providers to constantly "think on our feet." It’s a real challenge to provide this kind of intervention.

5.32 At a home visit

Notes:

MIW SC:

At your last visit with Elizabeth, Susie tended to laundry during your visit and did not give you her full attention. When you arrive today, Susie says she wants to take a shower. Susie doesn’t seem to understand the intent of intervention is for her to learn skills and activities to support her child’s progress. How would you address this with her?

5.33 Suggestions for Mom

Notes:

MIW SC:

Did you consider Susie may need extra support and ideas to help facilitate her participation? You can spend some time during your session brainstorming with Susie ways she can tend to her needs at the same time caring for Elizabeth. Here are some suggestions for Susie...

• Be strategic about scheduling shower time

- Try to schedule shower when dad comes home from work. This can be “daddy time" with Elizabeth.

- Or shower during Elizabeth's nap time

• Set up a small area in the bathroom in which Elizabeth can have tummy time while Susie showers.

• Purchase an inexpensive clear shower curtain so Elizabeth is within sight.

• Ask for help… Ask a family member or trusted friend to sit with Elizabeth while you tend to your personal needs.

5.34 Activity: Service delivery scenarios

Notes:

MIW SC:

You may encounter other challenging situations when providing services in a family’s home. Take a look at the following scenarios and think about what you would do.

How do your responses coincide with your agency’s home visiting and safety guidelines? Discuss with your supervisor.

Challenging Situations: What Would You Do?

When providing services in a family’s home, you may encounter a challenging situation. Read the following scenarios and think about how you would respond. How do your responses relate to your agency’s home visiting and safety guidelines?

1. As you are pulling up to the home, you see that the family dog is outside guarding the front door. She begins barking more aggressively as you approach the gate.

2. You knock on the door and an unfamiliar person answers. He says that mom is not home, but the child is there. He offers to participate in the visit in her place.

3. Your appointment is for 9:30 a.m. You arrive at 9:50 a.m. Mom is upset because you are late and to her it seems like you don’t care about her or her child.

4. Both parents are present during your visit. As you review their child’s progress, mom reports she thinks the child is fine and does not need services, while dad is still concerned the child is not walking. They begin arguing loudly.

5. You are scheduled to visit a child who lives with an uncle who appears to be in a gang. At a previous visit, you heard him talking with friends about a fight and one of them made a comment about a gun.

6. At the evaluation, the grandmother was present and provided most of the information. But now in your first visit with just the mom, it seems as though the she is having difficulty understanding much of what you are saying.

5.35 Review

Notes:

MIW SC:

We've taken a look at the four components of all ECI services, and we've seen how they each play an important role in the coaching process. You've also started to apply what you know to some challenging situations. Great job!

Remember the four components of service delivery:

• The service triad

• Addressing routines

• Using everyday materials

• Teaching strategies to the caregiver

Also, remember the five steps to the coaching process:

• Joint planning

• Observation

• Action or practice

• Feedback

• Reflection

I'm headed out to a home visit with Andre's family. Take some time with your coach to learn more about the importance of cultural competence in your service delivery. I'll check back with you in a bit...

5.36 Activity: Cultural effects on service delivery

Read the following scenario and then answer the question.

Scenario #1: You feel that it is important for a child’s oral motor development to get her off the bottle and to start her drinking from a cup. Mom is not ready to take her off of a bottle because she is her last baby and her other two children were still using a bottle at that age. They turned out fine.

The child is making progress on all of her other goals. Mom is just more concerned about getting her to talk and not throw tantrums anymore.

Question: What would you do in this situation?

A. Keep coming at lunch every day to make sure Mom starts using a cup. If she doesn’t, you can do it for her once a week.

B. Respect the mom’s feelings and bring it up down the road to see if her priorities have shifted.

C. Clearly the mom does not have her child’s best interest in mind. Keep a close watch to see if there are other indications she is neglecting her children.

The correct answer is B, respect the mom’s feelings and bring it up later. You are taking into account the activities, priorities, and interests of the family. At this time, the mom would rather focus on other things. A is not correct because remember, you are not there to do one-to-one therapy without the family. You are there to coach mom on activities that are of importance to her and the family. C is not correct because when a family does not do the activities you have recommended and coached on, it is not because they do not care about their child. Be an active listener and find out what is important to the family.

Now, read the second scenario and answer the question.

Scenario #2: Mom is feeding her 34 month old daughter with a fork and immediately wiping her face after each bite. Daughter tries to grab the fork and help, but Mom says, “No, no, you’re going to get it everywhere!"

Question: What would you do in this scenario?

A. Take the fork and give it to the child because she needs to learn how to feed herself.

B. Let mom know she may cause her daughter to have sensory issues or that a delay in feeding could result in her daughter being held back in a younger class.

C. Talk to mom about the importance of allowing her daughter to attempt to feed herself and offer suggestions on less messy ways to do meal time. For example, the family could have a picnic outside.

The correct answer is C, talk to the mom about the importance of allowing her daughter to attempt to feed herself. While you are addressing a developmental need, you are being respectful of mom’s discomfort and offering an alternative. A is not correct because Mom is probably uncomfortable with the potential mess her daughter will make. Offer mom suggestions to allow her daughter to feed herself in situations that are easy to clean up. B is not correct because scare tactics are not a helpful approach. Mom may just be concerned about the mess. Offer mom suggestions to allow her daughter to feed herself in situations that are easy to clean up.

5.37 Activity: Cultural Scenarios

Notes:

MIW Coach:

What would you do if you were the service provider in these following scenarios? Jot down your thoughts. Then debrief with your supervisor; you might even consider role-playing the scenarios with your supervisor or another staff member. What did you discover?

Scenarios:

1. An ECI team is working with a Guatemalan immigrant mother and her 13-month-old daughter. The PT recommends that the daughter should be barefoot as much as possible while she is learning to walk. The mother disagrees. She is concerned about parasites in the soil – a common danger back in rural Guatemala – and how others might view her as ignorant if her child is not wearing shoes.

2. The Miller family are advocates for co-sleeping and have a family bed for themselves, their 4 year old daughter and their 1 year old son, Josh. Josh is having trouble settling down to sleep and staying asleep for the night. The EIS recommends that he sleep in a separate bed for safety reasons and to help with his sleep routines. The Millers feel it is important for his social emotional development to sleep in the family bed.

3. Lisa is a new SLP assigned to the team. At her first visit, she compliments Maria (mom) on how pretty Monica looks. Maria seems anxious and doesn’t share as much information after Lisa compliments her. Later Lisa learns about Mal de Ojo from her coworker. She wonders if Maria’s anxiety was caused by complimenting Maria without touching her.

5.38 Activity: Different parenting practices

Notes:

Remember the 7 key principles? #6 is: The early intervention process, from initial contacts through transition, must be dynamic and individualized to reflect the child’s and family members’ preferences, learning styles and cultural beliefs.

Talk with three colleagues on strategies they use when the family’s parenting practices, priorities or family activities are different than what you would recommend. Record their ideas, then debrief with your supervisor.

5.39 Resources for service delivery

Notes:

MIW SC:

Sometimes it can be challenging to think of activities to suggest to families. You have a variety of resources that can help.. Remember to look to typical child development for ideas on appropriate service delivery activities. Resources can be found in the SST Workbook, the ECI library collection at the Texas Department of State Health Services AV Library, classes at your local community college, and the Born Learning website, just to name a few. Another valuable resource is the HELP at Home curriculum, which contains reproducible activity sheets for parents and caregivers. Your program may have a copy of HELP at Home. If not, it is available for checkout from the ECI Library Collection.

ECI team members can be great resources. All ECI services occur within the context of a team, and because we are addressing the whole child within their family routines, the knowledge of an interdisciplinary team is important. Look to your other team member for support when:

• The child is not making progress after implementing a variety of strategies,

• The child’s developmental needs are beyond your experience or training, or

• The relationship between the parent and the child seems to be a factor in lack of progress

You can refer to the Continuums of Services handouts to guide you in determining if you need to involve another service provider.

Here is a list of the resources and where you can locate them:

SST Workbook (available on the Extranet-you must get from your supervisor)

ECI Collection (at the Texas DSHS Library):

Born Learning website:

Classes at your local community college

HELP at Home curriculum: You can view the paper copy at your local program.

Continuums of Services: {07D0901F-86B6-4CD0-B7A2-908BF5F49EB0}_59/service_continua.pdf

Documenting Service Delivery

5.40 Importance of documentation

Notes:

Documentation of service provides evidence of the work you have done. Maintaining a detailed record of all services is required by ECI and by our funding sources such as Medicaid and private insurance. It is also a valuable part of your service. When you write your progress note in a home visit, it is done in partnership with the caregiver. The note records what was taught, suggestions for routines in the coming days, and child progress.

5.41 A good progress note

Notes:

During a home visit, you are delivering a service that was determined in the IFSP to be needed and necessary, so the emphasis in documentation should not only be on “what” was done but “why” it was done. Progress note documentation needs to clearly reflect your professional intervention by describing how you applied your professional knowledge when you were coaching and teaching the parent. Every progress note will reflect what you as a skilled professional did and what information you provided. Ask yourself “what did I do during the service that required my professional expertise?”

5.42 Elements of a good progress note

Notes:

MIW SC:

ECI has specific rules about documentation of services. To meet the requirements of rule, your progress note for a visit must contain a description of the methods you used to engage the parent or caregiver, and include several pieces of information. Take a look at this list.

Elements of a good progress note:

• Current status/Changes since last visit- This will include relevant information that is specific to the stated outcomes listed on the IFSP. What did the parent/caregiver practice since your last visit? How did the techniques fit into daily life? Was the parent comfortable with the techniques and how did the child respond? Is the parent seeing progress toward the child’s outcomes?

• The IFSP outcome that was the focus of the intervention- Your progress note should clearly state the IFSP outcome (or outcomes) you and the caregiver worked on. In addition, all of the modeling, coaching and discussion you document need to clearly relate to the stated outcome and the reason for the intervention.

• Activities completed with caregiver and child to address stated outcome- Documentation should clearly reflect the focus of treatment was helping the family learn ways they can interact with their child to support the child’s development and learning. Your progress note should describe how you helped the parent to implement learning opportunities in daily life (coaching and modeling) and how you helped them find ways to adjust routines and strategies when necessary. Teaching and feedback needs to be described in your progress note including the parent/caregivers opportunity to practice (return demonstration) what you just modeled for them. Indicating you and the caregiver “encouraged” a child to do something is not documentation of a professional, skilled service. You should also document the use of materials or toys used were found within the home or child care setting.

• Progress toward outcome/outcomes addressed- This is where you, the professional, will document the application of professional knowledge and judgment. You must document the child’s progress or lack of progress and an assessment of the effectiveness of the intervention (ongoing assessment). You are expected to be constantly assessing and adjusting your strategies, activities and methods based on the child’s response to the intervention and the family’s success in using the intervention.

• Service provider’s signature- In signing the progress note, you are asserting that you provided a needed, skilled and necessary professional service, and the documentation is a true and accurate reflection of the activities of your session.

Other record keeping requirements apply to every progress note written in ECI. Each note must include the name of the child; the name of the ECI contractor; the name and the discipline of the service provider; the date; the start time, length of visit, and place of service; and the method of the service (individual or group).

In many ECI programs, providers leave a copy of the progress note with the family at the end of the visit. Some programs require that the parent or caregiver sign the note. The note provides a record of what they learned ideas of how to implement techniques and strategies, and reminders of things to work on until the next visit. There is not a need to write separately about “things to work on till next visit” because your entire progress note should provide this information. For the time spent writing the note to be considered part of your intervention, it should be written in cooperation with the parent and throughout the session. This type of documentation is referred to as concurrent documentation and should take place during every visit.

5.43 Identify parts of a progress note

Notes:

MIW SC:

This is a progress note for Andre. It's for his third SST session.

Notice an abbreviated outcome is written.

Take a look at the following progress note and see if you can spot these components of a good note:

• Coaching and instructions to the family or caregiver

• How activities apply to child and family routines

• Modeling interventions within everyday learning opportunities

• Skilled, professional service

• Child's response and progress

Beginning of Progress Note:

Current Status, Changes since last visit:

He is pointing and gesturing more to try to tell foster-parents what he wants with the snack time signs he has learned, but still not using many words to ask for toys or food. He is having fewer tantrums but still showing signs of frustration when unable to communicate his wants like throwing his snack off the table last week or just saying “No."

IFSP outcomes worked on: To use words and gestures

Activities with caregiver to achieve outcome:

Arrived during play time. Foster mom Lydia present as well as foster brothers. Andre was playing trucks with brothers. I helped Lydia, Andre and foster siblings in making a positive behavior chart to be used throughout the day. Andre enjoyed coloring on the chart. Lydia is educated on use of sticker rewards when Andre uses his words. Andre offered a sticker to place on the reward chart after asking for a cup. Reminded Lydia to place books out of reach but within Andre’s sight so he would have to request the book. Andre points to books on top of the book shelf. Lydia practiced the sign with Andre for book using hand over hand method while speaking the word, “Book”. Lydia is reminded to continue to practice these techniques and strategies throughout the week and during playtime and mealtimes.

Child’s Response to Intervention/ Progress toward outcome addressed:

Andre remained motivated and eager to participate throughout today’s visit. Andre was able to point to the book he wanted and used the word “book” for the first time today. Good progress noted in today’s session. Lydia is becoming more comfortable with new signs and use of strategies.

End of progress note.

Here are the answers:

Coaching and instructions to the family or caregiver:

“Reminded Lydia to place books out of reach but within Andre’s sight so he would have to request the book.”

“Andre remained motivated and eager to participate throughout today’s visit. Andre was able to point to the book he wanted and used the word “book” for the first time today. Good progress noted in today’s session. Lydia is becoming more comfortable with new signs and use of strategies.”

How activities apply to child and family routines:

“I helped Lydia, Andre and foster siblings in making a positive behavior chart to be used throughout the day.”

Modeling within everyday learning opportunities:

“Andre offered a sticker to place on the reward chart after asking for a cup.”

“Andre points to books on top of the book shelf. Lydia practiced the sign with Andre for book using hand over hand method while speaking the word, “Book”. Lydia is reminded to continue to practice these techniques and strategies throughout the week and during playtime and mealtimes.”

Skilled professional service:

“Lydia is educated on use of sticker rewards when Andre uses his words.”

Child’s response and progress:

“He is pointing and gesturing more to try to tell foster-parents what he wants with the snack time signs he has learned, but still not using many words to ask for toys or food. He is having fewer tantrums but still showing signs of frustration when unable to communicate his wants like throwing his snack off the table last week or just saying “No."

“Andre was able to point to the book he wanted and used the word “Book” for the first time today.”

5.44 Activity: Writing Good Progress Notes

Notes:

SC:

Take a look at these two service delivery notes for a home visit with Riley. You will decide which note incorporates the elements of a good progress note after reading the two notes.

Example Note 1, Beginning of Note:

Date: 11/01/2014

Name: Riley

Current Status; Changes since last visit: SLP arrives at family’s home. Mom and child are present. Child is playing on the floor with toys when SLP arrives. SLP asks mom how Riley is advancing towards his outcomes. Mom reports she had a hard time in the grocery store. SLP asks mom what she could have done differently and what she would like to change.

IFSP Outcomes worked on: Tantrums

Activities with caregiver to address outcomes: SLP coaches mom in techniques to improve Riley’s compliance with use of strategies. SLP demonstrates use of cards provided at last visit and tells mom to use her cell phone as a timer when in the grocery store. Mom reports understanding on techniques and agrees to continue working towards outcomes.

Reminders; things to practice till our next visit: Use cell phone as timer and use picture cards in grocery store.

End of Note 1.

Example Note 2, Beginning of Note:

Date of service: 11/01/2014

Childs Name/DOB: Riley, 07/01/2012

Service Provider Name and Service: Brianna Fantana, Speech Therapy

Start Time and Duration/ or End Time: 11:00 am, 60 minutes; or, 11:00 am to 12:00 pm

Method and Location: Individual/ Home

Current Status; Changes since last visit: SLP arrived at Riley’s home. Riley, Mom (Adelia) are present. Riley was playing on the floor with trucks. SLP asked Adelia how her week was and how her last trip to the grocery store went. Adelia reported using the picture exchange system but Riley only remained interested in the cards for about 5-10 minutes before he tried to run.

IFSP Outcomes worked on: Riley will be able to go to the grocery store without running away or displaying tantrums with use of the picture exchange system.

Activities with caregiver to address outcomes: SLP and mom brainstormed regarding the cards Riley found most interesting and areas of the grocery store Riley seemed to enjoy most. Adelia reports Riley enjoyed the toy section and the lobsters in the seafood department. SLP, Adelia and Riley made additional picture exchange cards to foster increased compliance and ease with transitions around the grocery store. Cards were made using index cards and magazines cutouts found in the home. SLP instructed Adelia in the use of the cards and suggested use of a timer on Adelia’s cell phone as a preparatory strategy technique. Adelia practiced using the newly made picture cards and cell phone timer to encourage Riley. SLP provided feedback and Adelia and Riley practiced these techniques again. SLP recommends to Adelia to practice these techniques in the upcoming week prior to her next trip to the grocery store with Riley. SLP will meet Adelia and Riley at the grocery store for the next weeks scheduled SLP visit.

Child’s Response to intervention/Progress toward outcome addressed: Riley was receptive to the activity and participated well in choosing the pictures for the cards. He was able to follow directions during the task and remained focused for 15-20 minutes.

Staff Signature/Title: Brianna Fantana, CCC-SLP

Parent/Caregiver Signature: Adelia Smith

End of Note 2.

Question: What do you think? Which one incorporates the elements of a good progress note?

A. Example 1

B. Example 2

The correct answer is B, Example 2. This is a good example of a progress note. There is a clear definition of child progress in this note. There are specific examples of coaching with the family. There are specific examples of how the service is addressing the IFSP outcome. There are also specific examples of return demonstration. The note reflects how this strategy will be implemented into a typical family routine.

Example 1 does not provide specific examples of coaching with the family. The note is very directive and does not reflect a partnership between the provider and the parent. It does not provide a clear example of return demonstration. It does not reflect how the service is meeting the IFSP outcome, nor does it reflect a clear description of child progress. Although a typical family routine was mentioned (going to the grocery store), the note does not reflect how the service provider implemented the intervention during a routine or a clear example of how the technique should be used in a routine.

5.45 Activity: Concurrent Documentation

Notes:

Wilma Ferrell, OTR arrives at Elizabeth’s home for her scheduled weekly service delivery. A narrative of the home visit is provided here in six parts. You will need the handout, sample progress note, to write in as you go.

After you read what happened at each part of the visit, you will stop and write in the sample progress note as you go. You will get a prompt, “write,’ which will cue you to stop and write the note.

Elizabeth’s outcome: Elizabeth will hold her head up to look at her mobile.

Beginning of narrative:

Part 1: Once in the home the Wilma asks mom (Susie) how her week was and how she felt when working on Elizabeth’s outcome to improve Elizabeth’s ability to lift and turn her head. Susie reports she has been working with Elizabeth on her stomach and trying to get her to lift her head to look at her toys but it isn’t working very well.

Stop and write.

Part 2: Wilma then asks Susie to show her how she places Elizabeth on her stomach. Wilma praises mom for her work and suggests trying a new technique that will help Elizabeth.

Stop and write.

Part 3: Wilma asks mom for a small towel and places the rolled towel under Elizabeth’s chest and arms to help prop her up. Wilma then has mom try the technique of rolling the towel and placing it under Elizabeth. Susie is excited to see that Elizabeth is then able to lift her head for a short time to look her favorite rattle.

Stop and write.

Part 4: Wilma then asks Susie if there is anything else that she may be having troubles with. Susie shares with the Wilma that she is worried about the baby’s head when she is sitting her car seat. Wilma delves deeper into the conversation asking mom to show her what she is concerned about. Susie takes Elizabeth and places her in her car seat. Wilma can see that Elizabeth’s head is leaning to the left. Wilma talks to Susie about working on this more and asks mom for her thoughts about adding this as an outcome. Susie is happy that Wilma will help her to work on this because she has been very worried about Elizabeth and she wasn’t sure how she would do once she starts daycare.

Stop and write.

Part 5: Wilma takes the small towel and then demonstrates to mom how to roll the towel and place it next to Elizabeth while she is sitting in her car seat. Wilma then lets mom try this technique and even has mom take Elizabeth in the car seat and try the positioning when the seat is placed in the car. Wilma video tapes this strategy on mom’s cell phone so that she can refer back to the video and practice during the upcoming week.

Stop and write

Part 6: Wilma then asks mom how she felt about this technique. Mom reports she would like to practice this more and then decide how it works for Elizabeth. Wilma then spends some time with mom reviewing the note with the new strategies and techniques provided during today’s session. Wilma encourages mom to continue practicing during the upcoming week and reminds her to use the cell phone video. Wilma thanks Susie and confirms next week’s visit time.

Stop and write.

End of narrative. Finish progress note.

Reassessment

5.46 Reassessment

Notes:

MIW SC:

We discussed planning the reassessment in the IFSP section of Making It Work. Now let’s discuss documentation of that activity.

As you learned in the section on Periodic Reviews, the IFSP team must assess the effectiveness of the services of every enrolled child at least once every six months. If Specialized Skills Training (SST) was planned, the specific requirement is that the child receive either a regularly occurring service by the LPHA (like physical therapy) or re-assessment by the LPHA at least every six months.

When you are the designated LPHA on the IFSP team you have a responsibility to document, at least once every 6 months the following:

• the child’s functional abilities and progress towards the IFSP outcomes,

• whether services are responsive to the family’s goals for the child, and

• recommendations for modifications to the plan

No formal testing is required for the this type of reassessment, it is merely a review of the current plan and services However, if in your professional opinion you must use a standardized assessment tool to complete this task, written consent from the parent would be required, and the documentation would include more than reporting of the test results. It’s important to relate the assessment results directly to the IFSP outcomes and to the functional abilities of the child, as well as any areas of continued concern or difficulty. There should always be a direct correlation between the needs or concerns of the child and family and the reason for changes to the IFSP.

5.47 Reassessment Documentation

Notes:

Whether you are providing on-going services to the child, or providing the re-assessment service, documentation at least every six months includes:

• Observations of the child in his home, childcare, or other settings that are most related to the outcomes in the IFSP.

• Communication with the family about their goals for their child and their perception of their child’s progress or lack of progress toward the IFSP outcomes.

• Communication with all team members and caregivers regarding progress towards outcomes, barriers to obtaining outcomes, and any additional outcomes that may be needed.

• Application of your professional expertise and clinical knowledge as to why the IFSP does or does not need to be modified.

Remember it is not sufficient to document the child is making good gains towards all outcomes. You need to document detailed specifics about the child’s progress.

5.48 Activity: Andre's reassessment

Notes:

It is time for Andre’s 3 month reassessment as outlined in his initial IFSP. Complete the following four questions about Andre’s reassessment. Don’t forget to refer back to his SST visit notes to help you in completing this activity. The note to view is in section 5.43.

Question #1: Are the services on the IFSP addressing the outcomes/ goals? What do you think?

A. Yes

B. No

The correct answer is A, yes. However, mom is concerned more about Andre’s limited speech. EIS reports Andre is making good progress towards his current outcomes. Lydia, Andre’s foster mom, reports Andre is now more engaged with his foster siblings and will sit and play trucks for 20- 30 minutes or more. Lydia also reports that Andre is beginning to develop play skills and takes turns when playing with his foster siblings. Both the EIS and Lydia are concerned about the limited language development despite Andre’s opportunities and the strategies used.

Question #2: Is the service helping the parent to help the child develop? What do you think?

A. Yes

B. No

The correct answer is A, yes. Lydia is beginning to demonstrate good understanding of techniques to facilitate Andre’s cognitive growth, however she is voicing concern that Andre is not speaking much despite the strategies used. She is reporting that Andre just points at things he wants or says, “NO” when he doesn’t want something or will get upset. Lydia is telling the team that Andre becomes easily upset when he doesn’t get what he wants. Lydia has identified that she would like Andre to increase his communication skills in order to ask for toys and food items.

Question #3: Is the child making progress towards achieving the outcomes and are the interventions effective? What do you think?

A. Yes

B. No

The correct answer is A, yes. But notice the progress is slower than anticipated. The EIS has been working with mom on implementing strategies to promote Andre’s cognition and interaction within the family (helping to feed the family pets, playing family games and sharing with his foster siblings, reading books and encouraging Andre to following simple commands and signing). Mom is happy with the strategies and positive rewards activity that she and the EIS put together for Andre and the rest of the children, but remains concerned about his slow progress with producing words

Question #4: In the professional, informed opinion of the LPHA, are modifications to the IFSP needed? What do you think?

A. Yes

B. No

The correct answer is A, Yes. Modifications are needed, considering that Andre is now 23 months old and has a vocabulary of only 4-5 words and is not producing initial consonants. He is also not putting two words or phrases together such as “more milk." Delay appears to be in expressive language only as Andre’s comprehension appears age appropriate. Andre is able to follow simple one step directions such as “sit down” or “bring me your cup.” SLP is recommending speech services to be added to IFSP 4 x months to address Andre’s expressive language delay.

As a result of the re-assessment of progress and needs the SLP recommended the team consider adding speech therapy to Andre’s IFSP. The team agreed, and added the services to Andre’s IFSP.

Here are some examples of new outcomes the team created to address the family’s speech concerns.

Andre’s Reassessment, New Outcomes:

Outcome: Andre will use 4-5 different words to ask for food or drink items during meal times, 6 out of 7 meals, over a 4 week period.

Outcome: Andre will use 4-5 different words to ask for toys when playing with his foster siblings, 6 out of 7 days, over a 4 week period.

5.49 Conclusion

Notes:

Congratulations! You have completed section 5 of Making It Work, Service Delivery.

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