Implementation of a new service model was transformational
Implementation of Partnering for Change was more than just starting a new service. It required a transformation from an ‘old’ way of thinking about providing occupational therapy services in schools to a very different approach. Instead of remediating one child at a time, a health promotion lens was used to view the whole school and all of the children in it, including those with special needs and those children who were struggling and who might have previously remained unnoticed. The transformation process was complex and it took time to change ways of thinking and doing:
The transformation is huge…we’ve been at a pay-for-service delivery model for many, many years. All of us have to start to rethink.
— Community Care Access Centre
You are trying to change your practice but at the same time you are trying to tell all the teachers about the model and educate them about the model and you are trying to change what kids are doing and you are trying to change what the teachers are doing. There was so much that it was overwhelming
— occupational therapist
Think differently, right? You cannot think the traditional service provider model that we have; you cannot keep those thoughts in your mind. You have to get them out of your mind and think, okay, this is a different way of providing service.
— Community Care Access Centre
…as we learned by experience, then we could figure out the solutions, the things that were going to work, the strategies that were going to work. And it took months.
— P4C team member
A transition period is needed for successful implementation
Key stakeholder interviews identified numerous activities that needed to take place before full implementation of the P4C model in schools, including changes in documentation, tracking, billing and reporting processes. A significant issue for both the CCACs and the OTs was how to manage transferring children from CCAC active caseload and waitlists to the P4C OTs. Waitlists are eliminated in P4C, but the existing waitlists have to be dealt with first, during a transition year.
School board personnel and staff in each school needed to learn about the P4C model, how it differed from the previous model, and about their roles and responsibilities within the model. Presentations were given in every school, and were also provided for principals, resource staff, psychologists, speech language pathologists and Special Education Advisory Committees at a board-wide level in response to requests from school board partners. At the beginning of the school year, all parents in the P4C schools were sent a letter describing the P4C model and indicating how they could access the service.
There would be some changes needed in CHRIS [the information system]…to account for the model and to accommodate the model.
— Community Care Access Centre
We had to change the way they [the service provider organizations] were billing because in this model you can’t do individual child billing.
— Community Care Access Centre
…first we had to call all the parents [of children on the waitlist], do all that stuff, get all the paper work…then we had some invoicing issues.
— Community Care Access Centre
I know that that when we initiated this, it was setup in a certain way to…take on waiting lists…it was so broad and there were so many layers of things…
— occupational therapist
Another reason that a transition period is needed is that the foundational elements of the P4C model — relationship building and knowledge translation — are critical for successful implementation. Partnering for Change was delivered once per week for nearly two full school years. The importance of spending time to establish relationships between educational and rehabilitation professionals became really evident to multiple stakeholders during this time. Relationship building was also identified as a significant factor in the success of the prior demonstration project of Partnering for Change (Campbell, Missiuna, Rivard & Pollock, 2012).
Once [OT] become known to staff then, just like any support person, they’re in the school once a week…they become a familiar face, they gain trust. You build that relationship, then it happens.
— School board
…there is a good amount of information sharing so that we’re all on the same page and we’re all working together. And again the relationship piece comes through loud and clear.
— Community Care Access Centre
I think the relationship building was really, really key in all of my schools because from there I was able to build rapport on a very deep level with educators…and the knowledge translation was much better when I had the relationship in place.
— occupational therapist
Training and ongoing mentorship are essential for successful implementation
The eight online training modules and initial orientation workshop need to be completed by OTs before they start providing the new service model. OTs who did not have the opportunity to do this (e.g. due to sudden coverage for a therapist leave) commented on how difficult the transition was when the modules were not completed prior to starting to deliver the service. The group mentorship meetings that occurred throughout the two years of the project were reported to be necessary and highly valued to support the OTs in changing their practice.
Those modules were so helpful for us to wrap our heads around the long lasting effects of DCD and I personally learned so much from them. I knew DCD as a diagnosis but I didn’t understand how it really translates as children grow older within the education system.
— occupational therapist
I think that mentoring, that problem-solving discussion, was huge…when a program starts like that, face-to-face is vital. The strength of the P4C and the way we ironed out our issues so quickly, was because people came together. They all got the same message at the same time.
— School board
I think that mentorship piece is key…I think it would not be as successful if it were to span out on a big level without that piece built into it. I think what would happen is that…an ‘old’ model would just be replicated within me and I don’t think that we would see that agent of change or that sort of paradigm shift…
— occupational therapist
I think that if this is supposed to be going to move forward, as it should, I think that whoever is going to fund it…has to build that piece in. All of these resources that have been developed are so essential. Just the opportunity to brainstorm and share and vent and problem-solve is such a key component of it that I think it would not be as successful without that piece built into it.
— occupational therapist
The need for ongoing mentorship support was also identified in the measures completed by the OTs at the end of the second year. The OTs were asked to write “Pearls of Wisdom” to share with future P4C OTs, Managers and Funders, and the P4C Research Team. There were several comments and recommendations for ongoing mentorship and support including: “Providing monthly mentor meetings is essential; sharing resources, problem solving challenging situations to build and support the team.” Additional quotes are reported in Making a Difference for Occupational Therapists.
This theme is also consistent with the findings of Campbell, Missiuna, Rivard and Pollock (2012). Interviews with OTs who delivered the P4C service in a prior demonstration project also revealed the importance of ongoing mentorship support: “Monthly peer support meetings also were perceived as a critical component of the P4C project.”
Barriers were identified and strategies developed through strong partnerships
Throughout the two years of the project, barriers to implementation emerged. Because of the strong partnerships that had developed in the early stages of the implementation process, strategies to address most barriers were identified, tried, reviewed and revised as needed. The solutions that arose as a result of that collaboration now serve as recommendations for the future.
Parent Involvement
At the end of the first year of the project, many different stakeholder groups identified the need for the OTs to increasingly connect with parents. It was suggested that this contact would help to build parents’ capacity to understand their child’s needs and to enable parents to use strategies identified by the OT to facilitate the child’s participation. Barriers to parent engagement were identified and included: timing; if parents worked full-time; English as a second language; and the large size of some of the schools which resulted in an increased number of parents to be contacted. Parent readiness and the need for further information to help parents understand the change in service model were also cited as barriers to parent engagement. Although the OTs began to develop strategies to improve parent/family engagement in the second year of the project, it is recommended that innovative methods to connect with families continue to be considered and studied in the future.
…now we are doing things a bit earlier where we are the first point of contact…a lot of the times they [children] are in kindergarten or very early young kids where the issues are starting to kind of come into play and the parents are either not ready to accept it or they haven’t really seen it or had an opportunity to understand that piece of it.
— occupational therapist
So many times I would call parents to tell them [what I was doing] and they’d be okay, sounds great, do whatever. I’m glad you are helping!
— occupational therapist
At a smaller school, the parents were more accessible in terms of drop off or pick up, and I did have more relationships with parents. At my larger school I had almost no chance other than the odd phone call. I made contact with all of the parents at the beginning of the year as the new OT in that school but, even with that, many parents didn’t call me back.
— occupational therapist
The team noted that very few evening workshops for parents were offered during the transition period: these could be encouraged as parents who did attend were highly satisfied. A number of the OTs had other suggestions about how interaction with parents might be improved:
I made sure I had something in the newsletter, ‘please contact me if you have questions.’ I had a couple of parents who did call and, because it was parent initiated, I have been able to have good communication back and forth. Someone else was a parent volunteer who said ‘you know, I am wondering’…Parent initiation made a difference.
— occupational therapist
It’s hard during the school year sometimes to tackle everything because there are so many issues going on but I found in the past in the summer when we ran groups or camps that the parents were a lot more involved and a lot keener to implement stuff because they only had one thing to focus on. So that’s an idea, in terms of connecting with families, maybe doing something in the summer and then the parents can really be involved as well [be]cause they actively bring their kids every day which demonstrates the fact that they have some concern and they are willing to kind of do stuff to help them.
— occupational therapist
Waitlist Management
In the first few months of the project, the OTs faced challenges implementing the P4C model because the need to facilitate early identification through knowledge translation and collaboration with educators seemed to conflict with acceptance of, and immediate responsibility for, individual children from the CCAC active and waitlists.
Because I think what’s happening is we are trying to be the coach and the educator but we’re getting confused and thrown back into our old role of seeing kids one-on-one because of the Community Care Access Centre referrals that have been given to us.
— occupational therapist
And it wasn’t just the Community Care Access Centre piece, there was some pressure to get kids to the top of the model when we should have been spending more time probably the first six to eight months down at the bottom of the model, building our resources, getting into the classrooms…
— occupational therapist
Barriers were also identified by the OTs who delivered the P4C service in a prior demonstration project (Campbell, Missiuna, Rivard & Pollock, 2012). The OTs in the demonstration project reported challenges “balancing competing demands” and with the “sheer volume” of activities at the school.
In response to this challenge, the P4C Working Group developed strategies for the second year of the project to more gradually transition children off the CCAC waitlists to the P4C OTs, and this worked well.
Communication and Documentation Across Systems
P4C OTs need to access varied sources of information about each child in order to provide effective P4C services at all levels. Consideration needed to be given to who stores child files and how information is shared across health professional and educational reporting systems. Each school board approached issues of file storage and access to board intranet and communication differently. Communication and privacy issues arose during meetings with speech/language pathologists and with principals. Issues considered included: how will other school board speech/language pathologists or psychologists know about the P4C OT involvement? Can the OT access the school intranet? If the OT attends In-School Resource Team meetings, how is the OT’s input documented?
The P4C team worked with each board separately to identify the best resolution to issues that emerged, to ensure adoption of solutions that fit within the school board’s existing practices for communication and documentation. Legislation, policies about communication, privacy documentation, office space and access to technology are issues that should be addressed collaboratively and early in the implementation process.
Compensation for Occupational Therapists
One barrier that emerged at the end of the project was not able to be addressed during the study. Although OTs reported a high level of satisfaction with delivering the P4C model of service, the OTs identified a significant decrease in salary, compared with a fee for visit model of service in which travel costs are paid in addition to the visit. The role of service provider organizations in this type of service delivery has also changed because the OTs no longer bill for each visit and the documentation is greatly reduced. The extra layers of involvement and contact that are not value-added in the traditional model have been captured well in the Process Maps. Partnering for Change therapists provide much more direct service time and there are fewer steps involved in processing referrals. Compensation for direct provision of rehabilitation services in school settings warrants further consideration when this model is implemented.
I think the reality of things is that the funders need to keep in mind too in order to keep the OTs in this position you need to…pay them appropriately for the amount of work that they do.
— occupational therapist
I realized we are paid less than an entry level teacher and here we are using our own time. We show up and we do our best and it’s not always recognized.
— occupational therapist