Week 1

Focus on improving participation & performance of children

• By providing direct interventions

• Providing indirect interventions (consultation, education, coaching)

• Recommend environmental modifications &/or task adaptations

Essentials of Pediatric Intervention:

• Focus on improving participation & performance of children

• Focus on promoting inclusion

• Focus on providing intervention to foster inclusion

• Focus on facilitating child engagement

• Focus on creating Just-Right challenges

• Focus on promoting access & participation

• Focus on evidence-based practice (EBP)

• Focus on generalization of skills

• Focus on using various models of service delivery

Focus on promoting inclusion

Promoting social justice by advocating for inclusion

Children & youth with disabilities have right to participate in all aspects of life, across environments (AOTA, 2015)

Focus on providing intervention to foster inclusion

• Educating others (entities, individuals, community)

• Recommend modifications to increase physical access

• Adaptations to increase social participation

• Strategies to improve skills (motor, process, communication/interaction)

Focus on facilitating child engagement

• Developing client-centered intervention

• Engagement is essential

• Child’s brain responds and learns

• actively involved vs. receiving passive stimulation

Children are given choices

• Selecting interventions that target occupations important to the child (play, taking care of pets, etc.)

• Use of specific strategies to promote engaging in & addressing meaningful goals

Focus on creating Just-Right challenges

Create opportunities that match developmental skills & interests

Provide reasonable challenge to their current performance

Activities that keep them engaged & motivated

Foster self-efficacy, self-determination & confidence

• Opportunity to develop a sense of mastery

Focus on promoting access & participation

Interventions that modify, change or adapt environments

• Increase accessibility (e.g. accessible playground)

• Increase safety (e.g. widened doorways in school, home etc.)

• Interventions that modify, adapt task

Using technology to assist with participation

• Low tech (e.g. switch toys)

• High tech (e.g. augmentative communication devices)

• Appropriate sensory modifications to accommodate for sensory differences

Focus on evidence-based practice (EBP)

Research shows that EBP not routinely integrated into practice

Hospitals & medical teams, schools & educational systems & stakeholders have called for EBP & policies

Positive correlation between high positive outcomes & EBP

Focus on generalization of skills

Plan interventions that can be generalized across environments

Goal is not just for the child to do well during 1:1 session

Partnering with client & caregiver

Collaborating with other team members (teachers, SLPs, etc.)

Our role in primary care

Using coaching as an interactive style

Supporting parents to implement specific strategies

Focus on using various models of service delivery

Variety of service models in pediatric practice

Direct service- individual &/or group

In-direct services- consultation services with caregivers or other professionals; advocating for clients (universal design)

Push in vs. pull out in school settings

Fluid service delivery model (therapy as needed)

Recent research shows collaborative & inclusive interventions (indirect & push-in models) are the most effective

coaching as an interactive style

•According to Rush & Sheldon (2004) “Coaching is an adult learning strategy in which the learner’s ability to reflect on their actions is promoted in order to determine the effectiveness of an action or practice and develop a plan for refinement & use of the action in immediate & future situations.”

Why coaching as an interactive style?

Facilitates parental self-efficacy

Facilitates teacher self-efficacy

Evidence in improving parental & teacher competence

parental self-efficacy

– refers to how confident a parent feels in their ability to manage their parenting role which ultimately relates to & has an impact on effective care of their child (Benzies et al., 2013; Giallo et al., 2013; Guillamon et al., 2013; Heath et al/. 2015; Weiss et al., 2013)

– is indicative of both how well a child adjusts in their environment (Giallo et al., 2013) & of parental stress (Benzies et al., 2013)

–Parents with high sense of _ tend to use positive strategies & coping mechanisms that allow for resilience when caring for a child with disabilities (Benzies et al., 2013)

▪Parents tend to navigate tasks related to child care with positivity & determination

–Parents with low sense of _ may not be consistent at engaging with their children (Cohen et al., 2015)

teacher self-efficacy

refers to a teacher’s belief in their ability to successfully cope with tasks, obligations & challenges related to their professional role (Caprara et al., 2006)

Strong evidence in the literature that teachers with high levels of_ experience higher levels of job satisfaction, lower levels of job-related stress & more confident in dealing with students’ challenging behaviors (Caprara et al., 2003)

Facilitating teacher _ with the intervention plan

Evidence in improving parental & teacher competence

OT interventions addressing parental & teacher self-efficacy shown to improve occupational performance of children across environments (home, school, community)

Using coaching as an interaction style has shown to improve parental & teacher self-competence (Little et al., 2018; Graham, 2013; Dunn et al., 2012

Coaching

a type of practice within capacity building model to support clients & client constellation in using existing skills & to develop new skills to achieve desired outcomes. (Dunst & Trivette, 1994; Rush et al., 2003)

Family capacity-building

refers to the methods and procedures used by practitioners to create parenting opportunities and experiences to strengthen existing and promote the development of new parenting abilities in a manner that enhances and strengthens parenting self-efficacy beliefs.”

(Division for Early Childhood, 2013)

dependency creating examples

• caregivers see tele-intervention as a huge change in service delivery and is fearful of having to be responsible for the intervention

• the activity is created, provided, or decided. by the practitioner

• practitioner has his/her hands on the child (literally)

• practitioner tells the caregiver what to do

• learning only happens when practitioner is present

• caregiver says “we cant do this without u”

examples of capacity building

• caregivers see tele-intervention as merely not sharing the same physical space with the practitioner and continuing to be responsible for helping the child learn

• the activity setting for the visit is planned around what the caregiver naturally does with the child. no practitioner toy bag required on a televisit

• Practitioner has his/her hands around caregiver (figuratively). tele-intervention builds the capacity of the practitioner to hone his/her coaching skills

• practitioner helps the caregiver reflect on what he/she knows and learn new strategies

• learning happens as part of everyday activities with the caregiver and other family members based on a jointly developed between visit plan

• caregivers say “we got this”

Using Coaching as an interactive style

• According to Rush & Sheldon’s model (2011), the purpose of coaching is to acknowledge the existing body of knowledge & practices being used by a coachee as well as potentially enhancing that knowledge, while facilitating them to engage in a continual process of self-reflection & learning

• According to their model, coach is not the expert but instead serves to support the coachee in achieving specific goals (Rush & Sheldon, 2011)

• Coaching can be used to assess knowledge, facilitate growth & learning of specific content areas, promote EBP during interventions, analyze the effectiveness of interventions & provide support and feedback throughout the process

5 characteristics of coaching

•Joint Planning

•Agreement b/w coach & coachee on strategies

•Observation

•Observing either the coach or the coachee’s actions

•Action/Practice

•Opportunities for the coachee’s to practice, refine, or analyze new &/or existing skills

•Reflection

•Occurs when coachee reflects on existing strategies

•Feedback

•Coach provides info. to the coachee based on direct observations

NOT A LINEAR PROCESS

Coach’s Role- joint planning

Revisit previous plan- what have they been doing/practicing

In between visit plan- determine how and when will they utilize strategies discussed to practice skills

Next visit plan- determine what the OT and caregiver plan to address with the client during the next session

Coachee’s Role- joint planning

Shares what they tried

Identifies what they want to accomplish

Discusses what they would like to work on during next session

coach’s role- observation

Observe the coachee within the context of activities

• Look at both what the client & caregiver (coachee) are doing

• Activity analysis

Can happen formally or informally

Use modeling & demonstration as needed

coachee’s role-observation

Observe the coach model a behavior

Demo. good understanding of what the coach is modeling

Characteristics of coaching- Observation- Modeling

Definition: observation of the coach by the coachee:

•coach explains what they are going to do and why

•Give the coachee something specific to observe

•Coach models while the coachee observes

•Coach debriefs with coachee what happened during modeling

•Coachee tries what the coach modeled

•Reflection/Discussion

•Develop a plan as to how this strategy or activity will happen when coach is not present

coach’s role- action/practice

Supports the coachee in practicing, refining, and/or analyzing new or existing skills during real life context that occur during sessions

Observation & Action/Practice go hand in hand

coachee’s role- action/practice

Tries new ideas or actions that either were previously discussed & planned with the coach or resulted from a previous coaching conversation

coach’s role- reflection

▪Analysis of existing strategy

–Is it consistent with EBP?

–Is any adaptation or modification required to obtain desired outcome?

▪Use reflective questions to assist coachee in analyzing the current situation, encourage coachee to generate alternatives & actions for improving their knowledge & skills

coachee’s role- reflection

§Determines what worked or did not work?

§Why did it work or not work?

§Analyze and come up with alternatives or ideas for next steps

§Allows them to step back and think about what they know

Characteristics of coaching- Reflection (WILL BE ON EXAM)

awareness questions

analysis questions

alternative questions

action questions

awareness questions

•Promote understanding of what caochee already knows and can do

•E.g.- What have you tried?

awareness question

•Support coachee in comparing their current understanding to their desired goal

•E.g. What do you think will happen if…?

Alternative Questions-

Help coachee consider a variety of options to address desired goal

E.g. What else could you have done?

Action Questions

- Assist coachee in developing a plan for reaching desired goal

E.g. What do you plan to do?

Characteristics of coaching- Feedback

Information provided by the coach that is based on their direct observations of the coachee, or information shared by the coachee or the actions reported by the coachee. This information aims to expand coachee’s current level of understanding about EBP to affirm the coachee’s thoughts/actions

Coach’s Role - feedback

▪Uses knowledge when it is appropriate to affirm what the coachee says or does.

▪Provide positive feedback

▪May share further information to build on coachee’s knowledge & skills

diff types of feedback

affirmative

evaluative

informative

directive

Affirmative Feedback

Non-judgmental acknowledgement

E.g. “I hear what you are saying” or “I understand”

evaluative feedback

Supports strengths & appraises potential growth

E.g. “When you did that, child responded well.”

informative feedback

Shares expertise or knowledge

*ask before you share

directive feedback

Instructs coachee (only used in situations of danger)

Coaching Practices Rating Scale purpose

The scale is useful for assessing practitioner use of & adherence to evidence-based coaching practices in early childhood intervention

how to use the coaching practices rating scale

The scale is completed based on participation in or observation of:

• A single coaching session or a series of coaching interactions

• Coaching sessions b/w practitioner & family members or b/w 2 practitioners or b/w a supervisor & practitioner

• Used for self-administration

Telehealth- what is it?

Defined as “Application of evaluative, consultative, preventative, & therapeutic services delivered through information & communication technology.” (AOTA Position Paper, 2018, p.1)

Emerging model of service delivery

Minimize difficulties related to regional differences in access to therapists & therapy services

Telehealth- what does research show?

Huge change & shift due to the pandemic in 2020

• OTs “forced” to learn tips and tricks to using technology as a mode to provide OT services

General shift in attitudes towards telehealth

• Recent research results show-

  • 77% of OTs support telehealth (N = 176/230)

  • 78% support telehealth as a permanent option for OT services (N = 179/230)

Benefits include

• Improved parent/caregiver involvement which improved effectiveness of OT service

• Effective mode of service delivery for OT services (“see more clients on a given day”)

• Increase access to healthcare

Challenges include

• Technical issues

• Not effective with all populations (e.g. clients with significant cognitive challenges)

Teletherapy other names

tele-intervention, telehealth, tele-practice & virtual home visits

Basic requirements of teletherapy

Check with your state & clinic’s requirements, third party payer’s rules for reimbursement

Both practitioner & client/family receiving services should have access to technology

• Device (computer, smart phone)

• Internet

• Access to web base application (e.g. Zoom, WebEX, GoTo meeting, Teams)

Federal laws governing in-person practice such as HIPPA & FERPA also apply to telehealth practice

• Must maintain privacy & security of client’s info. (both electronic & environmental considerations)

Planning the visit - teletherapy

Plan to discuss about your first visit prior to the actual first virtual visit (Planning call)

• Discuss use of technology (perhaps parent education on use of technology)

• Discuss focus of therapy sessions (in natural activity settings such as mealtime, chores, self-care routine, etc.)

• Use coaching as an interactive style to facilitate collaboration

• Discuss use of device in facilitating observation of client participation (phone camera providing mobility)

• Discuss preferred mode of communication (email, phone, etc.)

  • List of objects (prior to session)

Agenda for the visit- teletherapy

planning, observation, facilitate reflection

Planning (3-part planning)- teletherapy agenda

Revisit previous plan- what have they been doing/practicing (quick check)

In between visit plan- determine how and when will they utilize strategies discussed to practice skills

Next visit plan- determine what the OT and caregiver plan to address with the client during the next session

Planning (3-part planning)- observation agenda

Essential step

Observe using your OT lens (both what the client & caregiver (coachee) are doing)

Have them practice

Use of modeling & demonstration may have to be modified (e.g. talk through, demo. using a doll)

Facilitate Reflection - teletherapy agenda

Open-ended questions to facilitate caregiver reflection

What worked, what didn’t work

Prompt to reflect on different ways to improve child participation

Provide feedback as appropriate

Be specific with feedback

Primary Care

SYSTEM OF PROVIDING PREVENTATIVE & CURATIVE SERVICES

GEARED TO IMPROVE HEALTH & PROMOTE CHRONIC DISEASE MANAGEMENT

EXPANSIVE DUE TO HEALTHCARE REFORM

FOCUSED ON POPULATION HEALTH

EMPHASIZES COORDINATION OF CARE

ADDRESSES SOCIAL DETERMINANTS OF HEALTH

ALIGNS WITH THE QUINTUPLE AIM

OTs in Primary Care Work

ACROSS THE LIFESPAN WITH WIDE RANGE OF CONDITIONS

AS GENERALISTS

AS INTERPROFESSIONAL TEAM MEMBERS

PROVIDING LONGITUDINAL CARE

CONSULTANT

Provides consultation during clinic

hours, also consistent with "intrusive” model of service delivery

CASE MANAGER/CARE COORDINATOR

Provide in-person and/or telephonic coordination of services based on health risk assessment

INDIVIDUAL PROVIDER

Conducts traditional service delivery, separate encounter in clinic or in client's home

GROUP FACILITATOR/ADVOCATE

Peer mentor group co-leader or collaborator

Where is primary care practiced?

Type of setting determined by organization, reimbursement method, availability of other professionals, and population needs

ACCOUNTABLE CARE ORGANIZATIONS (ACOS)

PATIENT CENTERED MEDICAL HOMES (PCMH)

PRIVATE/FREE-STANDING CLINICS

CLIENT'S HOMES

How is primary care reimbursed?

VALUE-BASED CARE

Reimbursement is based on outcomes or performance, not volume (such as fee for service)

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POPULATION MANAGEMENT

ACOs and PCMH focus on managing populations with cost-containment methods such as care coordination and risk mgmt.

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INNOVATIVE MODELS OF CARE

Primary Care Models, e.g., Comprehensive Primary Care Plus (CPC+)focus on access, engagement, planned care, and comprehensiveness

Evidence-Based Primary Care OT Practice

COST EFFECTIVENESS AND EFFICACY FOR INTERVENTIONS ACROSS LIFESPAN

INTERVENTIONS IDENTIFIED ARE:

• HEALTH PROMOTION AND LIFESTYLE MODIFICATION

• MGMT. OF MUSCULOSKELETAL CONDITIONS

• SAFETY AND FALLS PREVENTION

• PROMOTING ACCESS TO COMMUNITY RESOURCES

• DRIVING AND COMMUNITY MOBILITY RESOURCES

• FAMILY AND CAREGIVER ASSISTANCE & SUPPORT

• HOME MODIFICATIONS

TOP FIVE INTERVENTIONS for OT in primary care according to scoping review

ADVOCATING AND CONNECTING TO COMMUNITY SERVICES

CHRONIC DISEASE MANAGEMENT

SELF-MANAGEMENT EDUCATION

EHALTH PROMOTION

FALLS PREVENTION

*PREDOMINANT AMOUNT OF LITERATURE IS ON ADULT TO OLDER ADULT POPULATIONS

Primary Prevention

Roles for OT: Individual Provider Consultant

considerations

Determine roles, routines, habits that impact adherence to healthy habits, nutrition and physical activity

Identify barriers & supports to occupations that promote health

Review client's primary care health risk screening site's items that address prevention

Primary Prevention

Roles for OT: Individual Provider Consultant

ot processes: Evaluation options:

• Assess self-efficacy for balance and fear of falling using Falls Efficacy Scale

• Assess functional mobility for reaching items using Functional Reach Test

• Assess client's occupational adaptation and readiness for change to support recommended health behaviors using Occupational Circumstances Assessment Interview and Rating Scale (OCAIRS)

Primary Prevention

Roles for OT: Individual Provider Consultant

ot processes: intervention options:

1. Educate in techniques to utilize preferred occupations that promote healthy food choices and increase activity level

2. Provide motivational interviewing techniques to influence health behavior changes using meaningful occupations and engage the client in specific action plans by asking permission, eliciting change, exploring importance with open-ended questions, and emotion seeking skills

3. Address lifestyle modifications taking into consideration access to exercise facilities, transportation, cognitive abilities to use exercise equipment , meal preparation skills, and access to social/in-person supports

secondary Prevention

Roles for OT: Consultant

considerations

Determine other services child is currently and previously received

Collaborate with nurse practitioner to develop plan of

care and identify next steps with child's therapy team

secondary Prevention

Roles for OT: Consultant

ot processes: evaluation options

• Complete occupational profile to understand performance patterns, family and environment

• Consult with current practitioners providing service to child

• Assess sensory processing using parent-completed inventory and self-regulation questionnaire

secondary Prevention

Roles for OT: Consultant

ot processes: intervention options

Provide parent education on self-regulation techniques, including emotional regulation and sensory processing

Provide an OT developed sensory diet and mindfulness activities

Consult with nurse practitioner about finger skin integrity

tertiary Prevention

Roles for OT: Individual Provider, Group Facilitator, Care Coordinator

considerations

Determine current adaptive equipment resources an environmental supports

Collaborate with interprofessional team members on on-going needs of client

Understand end of life care planning and implications on interventions

Consider progression stage of condition and necessary community resources and support groups

tertiary Prevention

Roles for OT: Individual Provider, Group Facilitator, Care Coordinator

ot processes: evaluation options

Complete occupational profile to understand performance patterns, family and environment

Consult with current practitioners providing service to client

Assess person-environment fit within the home using I-HOPE and/or I-HOPE Assist

tertiary Prevention

Roles for OT: Individual Provider

ot processes: intervention options

Provide client and caregiver education on adaptive technique and equipment focusing on compensatory strategies

Provide supportive and educational services to formal and informal caregivers

Consult with interprofessional team on current status and impact on engagement in occupation and care planning

Discuss with client and family appropriate social and physical environmental supports

Connect client and family with services and resources (e.g., AAT, DME, local chapter support groups)