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Improving Systems, Practices, and Outcomes

Implementing and Sustaining an Effective Service Delivery Approach: Stages and Steps

Over the last 10 years, states' lead agencies for Part C Infant and Toddler early intervention programs began to seriously examine their approach to service delivery for infants and toddlers with disabilities and their families. Evidence from research, model demonstration and outreach projects has produced national awareness of validated practices in early intervention. There is a growing consensus about effective practices and the mission and principles of early intervention that are relevant across specific models, providing a "model neutral" view.

See: Key Principles and Practices for Providing Early Intervention Services in Natural Environments (2008)

In addition to the growing evidence-base, increasing pressure from federal monitoring, growing numbers of children served, and difficulties of recruiting and retaining various disciplines to work in early intervention also motivated states to closely examine how the service system was structured, and the nature and timeliness of service delivery. State administrators began to explore the various team-based approaches to find a way to provide more efficient and effective services and to extend the reach of scarce personnel. By 2011, 34 states were engaged in work to explore or change their service delivery approach.

This on-line guide presents 5 major stages for changing the service delivery approach and the critical considerations and steps that need to be addressed for each stage. Resources that have been developed by various national, states and local programs are included to provide examples of products, and processes for doing the work in each of the stages.

The stages and considerations were developed by analyzing 3 states' long term system change plans; reviewing the implementation literature (see NIRN, and NECTAC TA Model for Long-term Systems Change) and incorporating extensive feedback from NECTAC and NIRN staff with experience in implementing long term systems change. Resources were collected from a survey of state Part C Coordinators who are involved in this work, web searches and literature reviews.

The stages suggest a sequence of activities, but in actual implementation, some stages may be worked on simultaneously. Also, a change effort may begin at a later stage and then back track to do the work of earlier stages. The on-line guide is intended to facilitate exploration and implementation of a service delivery approach at any level of the system: state, regional or district, or a single local program. Many resources were developed from state-wide change efforts, but the implementation process and many informational and training resources are applicable for use by a local program, or a district or region, as well.

Five Stages

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There are many nationally known models, evidence-based components and practices and trainers who can support adaptation or adoption of various approaches. A state, regional or local program must consider how any approach "fits" with their infrastructure, management and staffing. Most important, all stakeholders should be included in exploring approaches, and determining the "fit" with their values and their vision of the mission and principles of early intervention. An articulation of the critical components of the approach, including practices, processes and procedures is vital to guide implementation.

Identify and bring together a diverse group of stakeholders that will develop a common understanding of the scope, mission and principles for the Part C Program.

  • Identify and bring together a stakeholder group including representation from state and local administrators, trainers and higher education teachers, service providers and parents
  • Define the scope and purpose of Part C services provided under their Infant Toddler Program
  • Develop or reaffirm mission and principles that will underlie the service delivery approach
Resources

Explore service delivery approaches or models to select the core features and components of service delivery that the state wants to adopt/adapt.

  • Review research and practice literature, gather information from other states and consultants
  • Identify desired core features and functions of each approach; discuss benefits, implementation process and potential fiscal impact
  • Choose the approach that best aligns with mission, values and desired direction for the state
Resources

Compare the current service delivery system and practices to the desired approach and articulate the desired outcomes/changes needed.

  • List the concerns /problems the state is trying to address, at all levels of the service system (e.g., state, regional, local services children and families)
  • List desired outcomes/changes for all levels that the new approach will address
  • Review infrastructure & current service delivery, including issues, concerns, strengths; what to keep and what to change

Begin discussion about how to implement, evaluate and sustain new approach.

  • Explore/measure readiness of potential adopters, commitment of leadership– (Begin to plan the evaluation questions and methods)
  • Study implementation and sustainability literature
Resources

Self Assessment on Effective Practices in Natural Environments: Integrating Child Outcomes Measurement into an Effective IFSP Process – NECTAC and ECO staff developed summary worksheets to facilitate a team discussion of the extent to which its program is integrating IFSP/IEP and outcomes processes: Summary Worksheet for IFSP Practices

Successful efforts in states to implement and sustain effective service delivery approaches have included these steps:

  • Identify and bring together a diverse group of stakeholders that will develop a common understanding of the scope, mission and principles for the Part C Program
  • Explore service delivery approaches or models to select the core features and components of service delivery that the state wants to adopt/adapt
  • Compare the current service delivery system and practices to the desired approach and articulate the desired outcomes / changes needed
  • Begin discussion about how to implement, evaluate and sustain new approach

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Successful implementation of any service delivery approach is dependent on widespread support among a diverse stakeholder group. Change requires champions, advocates and committed leadership. Stakeholders likely to be resistant should also be included and their input used to address concerns and garner more persuasive information. Building multiple communication channels with the field and using those channels to get information out and reactions and feedback to the implementers is vital. Implementers need to build public support through sharing the vision of infant and toddler services and the research and information that supports it.

Provide multiple opportunities to raise stakeholder group's awareness, understanding and commitment so that they can advocate with their constituencies to support the selected service delivery approach.

  • Make sure stakeholders understand the research and evidence base supporting service approach
  • Provide multiple opportunities to raise stakeholders' awareness, to get questions asked and answered, to clarify what supports or changes are needed to successfully implement
  • Use stakeholder input to tweak the service delivery approach and/or consider in the implementation plan
Resources

Identify administrators and decision makers whose buy-in will be needed to assure necessary support and resources for implementation and sustainability.

  • Identify within the lead agency and supportive agencies (Medicaid, state insurance, collaborators) who will need to be supportive of the changes
  • Use multiple relationship-building methods and communication strategies to turn them into champions who will help promote the service delivery approach

Develop communication plan to build statewide understanding and buy-in.

  • Identify a variety of "audiences" , messages, materials, and formats appropriate to each
  • Identify potential opposition, their issues and your response
  • Develop multiple communication strategies assure you disseminate information out to stakeholders and get feedback from them
  • Make sure your plan includes ways to use your stakeholders and champions to promote the service delivery approach
Resources

WA System Improvement Project's Newsletter

Develop, evaluate and refine "PR" materials/activities for your identified audiences.

  • Broadly disseminate the Purpose of Part C, Mission and Principles statements
  • Develop common language, benefits for all stakeholders (outcomes at all levels)
  • Describe core features/ components of the new approach to service delivery
  • Include evidence supporting the new approach
Resources

Successful efforts in states to implement and sustain effective service delivery approaches have included these steps:

  • Provide multiple opportunities to raise stakeholder group's awareness, understanding and commitment so that they can advocate with their constituencies to support the selected service delivery approach
  • Identify administrators and decision makers whose buy in will be needed to assure necessary support and resources for implementation and sustainability
  • Develop communication plan to build statewide understanding and buy in
  • Develop, evaluate and refine "PR" materials/activities for your identified audiences

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A long term implementation plan creates a path to achieving desired outcomes of adopting the selected approach. Activities at each level of the service system are necessary to assure desired practices are supported and maintained, including infrastructure changes at state and regional/district and local levels, and T & TA capacity necessary to provide and sustain needed training. Funding plans need to address both start-up costs of implementation, as well as continued costs of sustaining the desired approach. The most important task during this stage is to create a State Leadership Team and a local and/or intermediary Implementation Team, with consistent leader(s) and membership, which can develop the plan and oversee implementation. This team needs expertise in both the desired service delivery approach and implementation science.

Build State Leadership and Local Implementation Teams to develop a written implementation plan, oversee all activities, track timelines and evaluate and make adjustments as needed.

  • Be intentional about the Leadership team make-up with representation from all levels of the system, varied experiences and perspectives and understanding of implementation
  • The local team(s) should include service provider, administration, and intermediary administrative unit staff (if applicable) with varied experiences and perspectives and understanding of implementation.
  • Define the roles and responsibilities of the team members and their long term commitment to implementation and sustainability
  • Assure the teams have the resources, information and skills necessary to lead the change effort
  • Appoint team leaders / key contact people to convene regular meetings to develop a plan and do the work
Resources

Determine changes needed within state, regional and/or and local infrastructure, including funding mechanisms, to support and sustain the service delivery model.

  • Determine change needed to administrative structures to support desired change in practice such as: contracts, Interagency Agreements, general supervision/oversight, policies and procedures, guidance and forms
  • Determine changes needed in current funding mechanisms, find and align the fiscal resources to cover: start-up costs, infrastructure costs, resources, TA, training, materials, and new service delivery costs such as, team meetings, consultations, joint visits, etc.

Build state capacity for training and TA to support and sustain the new service delivery approach over time

  • Conduct needs assessments and plan T & TA activities ; determine T & TA materials, human resources needed
  • Review and revise licensure and certification requirements, as needed to align with service delivery model
  • Involve pre-service, higher education programs involvement to align pre-service teaching with service delivery approach
  • Develop an evaluation plan to understand the effectiveness and outcomes of T & TA planned
Resources

Write and disseminate the implementation plan to address all of the above with: activities, timelines, benchmarks, evaluation, roles and responsibilities.

  • Determine how to introduce and implement new approach over time (pilots, state wide implementation, incentives, and state-wide "kick-off", outside expert consultant?)
  • Develop communication and evaluation protocols, to assure on-going input from diverse stakeholders
  • Use stakeholders group to disseminate the plan widely and institute multiple venues to receive feedback
  • Incorporate important feedback and make changes to the plan to assure feasibility and timeliness
  • Use a variety of methods to widely disseminate the completed plan
Resources

Successful efforts in states to implement and sustain effective service delivery approaches have included these steps:

  • Build State Leadership Team and Local Implementation Team(s) to develop a written implementation team to develop a written implementation plan, oversee all activities, track timelines and evaluate and make adjustments as needed
  • Determine changes needed within state, regional and/or and local infrastructure, including funding mechanisms, to support and sustain the service delivery model
  • Build state capacity for training and TA to support and sustain the new service delivery approach over time
  • Write and disseminate the implementation plan to address all of the above with: activities, timelines, benchmarks, evaluation, roles and responsibilities

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The State Leadership Team and Local Implementation team(s) actively facilitates each implementation activity and evaluates if benchmarks of success are met (the activity has accomplished intended outputs). If not or not entirely, the team asks "why not" and problem-solves. Especially in initial implementation, planned activities may need adjustment; a different or supplemental activity may be needed. For example, a review of new policies and procedures may indicate areas where more clarity is needed or an evaluation of a training event or program may indicate that new procedural guidelines are necessary. Feedback loops are critical and the actual written plan needs to be continually revised and stakeholders kept apprised of any important changes. Piloting and field-testing all steps and outputs, including early implementation of practices is necessary to identify and make revisions, changes and adaptations before proceeding to full implementation. During initial implementation, the most pressing job of the State and Local Teams is to identify concerns or barriers to implementation or fidelity and use communication channels and feedback loops for rapid problem-solving.

Adapt and adjust infrastructure (state and local) to assure consistency with and fidelity to the core features and practices of the service delivery model.

  • Use communication channels and feedback loops to assure rapid problem-solving, especially during initial implementation
  • Adjust administrative structures, revising contracts and Interagency Agreements as necessary
  • Provide general supervision/oversight and implement credentialing programs
  • Revise policies and procedures, guidance and forms
  • Develop and implement fiscal policies and procedures and funding mechanisms
Resources

Build training and TA capacity and implement training and TA Plan activities at all levels: state-wide, regional, program, teams, individual providers, and families.

  • Develop guidance and training materials, such as: on-line courses, written manuals, workshops agendas and presentations, etc.
  • Implement training and TA Plan activities at all levels, such as: kickoff presentations, workshops, mentoring, reflective supervision, peer modeling, program visits
  • Maintain relationships and provide materials to higher education and professional organizations to impact preservice education and licensing requirements
Resources

Begin implementation of service delivery approach, using communication and evaluation protocols to problem solve barriers, test adaptations, identify additional supports or infrastructure changes.

  • Begin pilots; phase-in early implementers, assuring involvement of representatives of all levels of the system from local providers, administrators, intermediate administrative unit (if any), TA and training providers and State Leadership Team
  • Each pilot's work is embedded in the realities of local and state infrastructure and has its own implementation team
  • Leadership and Implementation teams oversee all aspects of implementation, reviewing evaluation information and feedback
  • Gather information about actual startup and implementation costs
  • Plan and test adaptations, putting any additional supports and resources in place as needed
Resources

Make necessary changes and move to full implementation, providing in adequate oversight and on-going support for practice.

  • Use evaluation and monitoring mechanisms to assure fidelity to chosen approach and that desired results are being achieved
  • Continuously update Implementation Plan with any changes in activities, timelines, benchmarks, evaluation, roles and responsibilities
  • State Leadership and Implementation teams continue to use information about what programs and providers need to continue and improve implementation and results

Successful efforts in states to implement and sustain effective service delivery approaches have included these steps:

  • Adapt and adjust infrastructure (state and local) to assure consistency with and fidelity to the core features and practices of the service delivery model
  • Build training and TA capacity and implement training and TA Plan activities at all levels: state-wide, regional, program, teams, individual providers, and families
  • Begin implementation of service delivery approach, using communication and evaluation protocols to problem solve barriers, test adaptations, identify additional supports or infrastructure changes
  • Make necessary changes and move to full implementation, providing in adequate oversight and on-going support for practice

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Thinking about sustainability is important from the beginning and throughout the implementation stages. From the beginning, the exploration of various approaches should consider what it will cost in fiscal, human and material resources to sustain an approach. After implementation is underway, building ways to continually check fidelity and success in achieving results with children and families must be built into on-going monitoring and quality assurance procedures. Most important, keeping track of progress, sharing successes, keeping champions (spokespersons and advocates) active and stakeholders aware and involved will keep on-going implementation a priority, rather than allowing shift from fidelity.

Continue to maintain and expand the support base for the service delivery approach, through a variety of on-going activities and strategies.

  • Make sure the Champions are active and new Champions are nurtured
  • Disseminate a variety of public awareness activities including evaluation results, child and family outcomes, testimonials, cost benefits, etc.
  • Keep the focus and priorities on continued quality implementation
Resources

State Guidance and Informational Documents on Services in Natural Environments and Transdiciplinary or Primary Provider Models: Materials Useful for Building Understanding and Support

Continue to review and revise infrastructure and provide fiscal resources to support on-going implementation.

  • Track information about on-going actual costs to support the service delivery approach
  • Review and revise policy, procedure, guidance, forms, program structures, job descriptions, team assignments and organization, etc.
  • Continue to explore and expand fiscal resources

Provide on-going orientation, training, TA and supervision to support fidelity to desired practices over time.

  • Recruit and orient new staff to be able to provide services according to the service delivery approach
  • Provide tiered training and support opportunities that match the experience and skill levels of all staff involved in implementation
  • Provide on-going mentoring, reflective supervision
  • Continuously fund team-level support and learning opportunities
  • Update and expand training materials, on-line courses, workshops, etc.
Resources

Conduct on-going evaluation of fidelity and quality practices.

  • Integrate measures of quality practice into on-going monitoring
  • Provide fiscal incentives for quality practice
  • Assure provider contracts support service approach
  • Leadership and Implementation teams use evaluation and monitoring results to maintain and improve the service delivery approach
Resources

MO First Steps IFSP Quality Indicators Rating Scale (QIRS) includes guidance and exemplars

Successful efforts in states to implement and sustain effective service delivery approaches have included these steps:

  • Continue to maintain and expand the support base for the service delivery approach, through a variety of on-going activities and strategies
  • Continue to review and revise infrastructure and provide fiscal resources to support on-going implementation
  • Provide on-going orientation, training, TA and supervision to support fidelity to desired practices over time
  • Conduct on-going evaluation of fidelity and quality practices

Supplemental Materials