Professional CornerAs a provider of "in-home" services I was very interested in how effective these services are viewed. Although complimentary as a hole, this article raises some good concerns, that bear contemplating, so that these issues do not become impediments to providing quality services. With Part C regulations, requiring "natural environments", it is more important than ever that quality and effectiveness are maintained.
Early Intervention at Home
June 14, 1999
By Danielle Campbell
Speech-language pathologists are pleased with the effectiveness of early intervention services provided in the home, but they feel that the way services are dispatched to families should be revised, according to a recent survey.
Respondents also noted that older children and those who are deemed ready may benefit from a combination of home and school-based intervention, reported Barbara Davis, PhD, CCC-SLP, associate professor in the Department of Communication Sciences and Disorders at the University of Texas in Austin. She conducted the survey to gauge clinicians' perceptions of the effectiveness of early intervention in homes across the state for children ages 0-3.
The survey addressed services provided to children who fit the state criteria for early intervention services. They presented with developmental disabilities, atypical development or medical risk factors that qualified them for intervention services.
A survey was sent to every program funded by the Texas Interagency Council for Early Childhood Intervention. Of the 134 surveys sent out, 58 were returned for a 43 percent response rate.
The 27-item questionnaire solicited the opinions of speech-language pathologists who work in home-base eariy intervention in Texas. The questions dealt with perceptions of service, team collaboration, family focus, effectiveness and outcomes. The clinicians could choose responses ranging from "strongly agree" to "strongly disagree."
Dr. Davis and Heather Northam, MA, CCC-SLP, monitored the responses for differences in urban and rural attitudes as well as contrasting opinions according to years of clinical experience. Northam, who now works for TheraCare, in New York, NY, was a graduate student at the time of the study.
Overall, the clinicians who were surveyed felt it was beneficial for the children to be treated in the home.
"The children were using familiar materials, and the therapists could demonstrate to parents how to use materials in a facilitative way to enable the child's development in their own context," Dr. Davis noted.
In addition, clinicians who provide services in the home are aware of the family's needs and have the opportunity to observe the child's day-to-day experiences.
The respondents indicated that there are fewer problems with carryover. Because the parents are not coached in an unfamiliar environment using unfamiliar materials, they are able to learn and incorporate new techniques in their home more readily.
Home-based services are more convenient and appropriate for some parents, the clinicians indicated, and children who receive early intervention at home make progress. Furthermore, because the clinicians took the time to go to the home, it was reported that families had more respect for home-based intervention and felt this kind of service was more personal.
However, the survey respondents did express reservations about the logistics of providing early intervention services in the home setting.
Many speech-language pathologists noted that the time spent traveling to a home cuts down on the time they could devote to intervention.
"Some clinicians said the taxing load of traveling and service delivery in the present mode was contributing to some burnout," Dr. Davis explained.
Having more flexibility in determining the mode of delivery would alleviate some of their stress, the clinicians stated.
"The clinicians feel time spent on travel would be more beneficial for treating children or doing research on how they could better treat children," commented Northam.
In addition, families occasionally were not at home or called at the last minute to reschedule appointments. If they were in a clinical environment, many of the respondents felt their time could have been better spent because they could have served another child.
Safety in the home and community was another concern cited by the clinicians. Sometimes it is decided that it is not safe to go into a neighborhood or enter a home for intervention.
"A home can be chaotic if the family is encountering personal difficulty," said Dr. Davis.
Any other problems the family is facing also may hinder service delivery.
Even when the family does participate in therapy, however, clinicians expressed concern that they are isolated from other parents and children receiving intervention services. Many speech-language pathologists said families that received intervention in the home missed out on opportunities to interact with and rely on other families for support.
Home care practitioners also feel isolated at times, Northam said, and services can be hindered by a lack of coordination among disciplines.
"The therapists work in the home by themselves, and they don't get a chance to meet with other therapists," she said. "If the home care program doesn't specify team meetings, there isn't a lot of coordination."
Furthermore, early intervention service providers feel their typical approach sometimes cannot be carried out because of a lack of equipment. Games and toys needed for speech activities may not be available in some homes. Clinicians sometimes want to bring other equipment as well but are not able to fit materials in their car.
The researchers reported disparities in responses among clinicians from different locations and with various years of experience in the field.
In an analysis of responses with a high standard deviation across respondents, Northam identified differences in the responses of practitioners from rural and urban areas on several questions. For example, nearly twice as many rural professionals felt that the current home health care system provided the optimum environment for consultation and training with other professionals.
This disparity could have developed because home-based intervention has been practiced longer in rural areas, Northam speculated, or because urban professionals had an expectation of more training and collaboration.
Urban clinicians were less likely to agree with statements that home-based care was sufficient to meet the needs of the family and used adequate staff to meet the needs of the children.
Practitioners with more than five years of experience felt that some children need to receive early intervention therapy in environments other than the home.
"Clinicians are concerned that children who are somewhat older and ready to profit from classroom interactions with other children their age .are not afforded that opportunity when all of the therapy is done in a home-based setting," Dr. Davis said.
The respondents suggested being able to use an individualized approach to providing service, with some children being served exclusively in the home and others receiving therapy in school and at home.
Because the survey was initiated before the Balanced Budged Act of 1997, the clinicians did not comment on issues that have arisen since the Medicare revisions went into effect.
For More Information
Barbara Davis, PhD
Jamie Heather Northam
Danielle Campbell is an editorial assistant at ADVANCE.
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