FAB Scheduling

FAB Scheduling stands for 'Flexible Activity Based Scheduling' that involves 'bursts of service'.

Frequency and Intensity of Service

Once the decision is made regarding who will serve as the Team Lead for a particular child and family, the frequency, intensity and duration of the support provided by the Team Lead and any needed Joint Visits with the Secondary Service Provider (SSP) must be specified. Previous methods for determining frequency and intensity of services have been discussed in the literature since the 1980’s and determined ineffective. The decision-making criteria have included but not been limited to, the child’s age, severity of the child’s disability, family socioeconomic status, mother’s education level, availability of time in the practitioners’ schedules, child therapy history, practitioner judgment of the parents’ ability to follow- through with a home program, third party reimbursement caps and cognitive referencing (Atwater, McEwen & McMillian, 1982; Borkowski & Wessman, 1994; Carr ,1989;Cole, dale and Mills 1990 Cole & Mills 1997;Cole & Mill 1991; Farley, Sarracino & Howard 1991; Krassowski & Plante 1997; Notari , Cole, & Mill 1992). In a study in early intervention, Hallam, Rous, Grove, and LoBianco (2009) reported that child and family factors including age at entry into the program, gestational age, Medicaid eligibility, use of third party insurance and child’s development levels influenced the amount if services provided. Other authors have described factors such as the teaming approach used, values and philosophy of the early intervention program, and management and delivery of services as highly influential on the type and amount of early intervention services received (Dinnebeil et al., 1999). Palisano and Murr (2009) discussed perspectives on the intensity of occupational therapy and physical therapy services for young children with development considerations. This discussion included the concepts of episode of care, readiness of their child for activity and participation, method of services delivery, and the effect of practice in natural learning environments as options for determining intensity of therapy services. Although multiple variables have been discussed in the literature in terms of making decisions about how much intervention should be provided to individual children, no method emerges as a clear evidence-based strategy for making these types of decisions.

The National Early Intervention Longitudinal Study (NEILS; Hebbler et al., 2007) stated that the majority of children enrolled in early intervention received 2 hours or less of service per week during the first 6 months. The findings from NEILs corroborate the results of earlier studies indicating that children were receiving 1-2 hours per week of early intervention services in 1192 and 1998 (Kochanek & Buka, 1998a, 1998b, Shankoff et al.,1992)

When using a Team Lead approach to teaming, the frequency and intensity of services listed on the IFSP should include the Team Lead as well as any and all SSP’s. A flexible approach to scheduling is necessary in light of the absence of empirical data on frequency and intensity of service and in consideration of the use of natural learning environment practices and the mission of early intervention to support the parents’ and care providers (related to the child’s strengths and needs) and the priorities chosen as outcome on the IFSP. This approach is referred to as FAB scheduling, which is flexible and activity – based and involves “bursts of service.”

Scheduling that is Flexible
Intervention is traditionally scheduling in blocks. For example, an early intervention practitioner identifies time slots during his or her week for visits with the individual children and families. Once a child is places in a time slot, regular visits occur on the same day at the same time unless the practitioner or family needs to reschedule the appointment for a specific reason. The advantages to a blocked scheduling approach are that it is easy for the parent and the practitioner to remember. (e.g., Ramon on Tuesday@ 2:00pm) and it is easy for the practitioner to manage her schedule (e.g. Practitioner can plan ahead; knows when he or she has an available opening). In contrast, flexible scheduling has many advantages and provides available of the practitioner based on the immediate needs and priorities of the child and family/ each future visit is scheduled at the end of the prior visit based on the joint plan developed between the care provider and the Team Lead. For example, the Team Lead asks the parent when he or she should return for the next visit based on what the parent will be doing between visits. For urgent situations, the Team Lead can meet more frequently with the parent while allowing for needed time for practice and implementation between visits. The time between visits may increase as the parents’ competence and confidence in supporting the child’s learning and development increases. Flexible scheduling is more consistent with using natural learning environment practices specifically related to contexts in which children’s skills and behaviors typically occur throughout the day. Joint visits is an implementation condition of a Team Lead approach to teaming (see Chapter 6) a requires team members to be available to accompany one another when needed, often with short notification. A flexible approach to scheduling also allows more and varied options for joint visits.

Scheduling that is Activity Based
As previously mentioned, many practitioners plan visits with children and families based on open time slots in their weekly schedules. Another reason a practitioner might schedule at the same time and day is to capitalize on the absence of other siblings or important people in the childs’ life to eliminate potential distractions for the childs or perceived chaos the practitioner. This type of scheduling interferes with implementing natural learning environment practices. The child’s environment, no matter how distracting or chaotic the practitioner believes it to be, is the context in which the child must learn and the parents need to be supported in fostering child participation and development. Furthermore, if a practitioner schedules a visit at the same time each week, then he or she is either limited to intervention within the activity setting that would naturally occur during that time or forces to create activities that would not usually occur during their typical day. For example, if a child tends to avoid sensory experiences such as hearing loud noises, playing with other children , being hugged and cuddled, or eating foods with varying textures and the practitioner visits Wednesdays at 4:00pm when the children are engaged in television watching. Once the child’s participation improves in these activity settings, if blocked scheduling continues, then the practitioner may be inclined to create games for the young children to play to address the child’s sensory issues, such as Ring-around-the rosy, duck-duckgoose or red rover. With the parent in the kitchen cooking dinner, these additional activities are limited to when the practitioner or another willing adult is present to facilitate and supervise the interaction. The practitioner may also feel the need to create the games or other learning opportunities because he or she devalues the activity occurring at the time (i.e. children watching television).

Alternatively, if a practitioner is using activity –based scheduling, then each visit will be planned around the priorities of the parents or child care providers within the context of the activities that typically occur on that day and time. For instance, the child previously described would most likely need support during mealtime, bath time, tooth brushing, and bed time routines. The practitioner would plan to go at the time of day when these activities occur so that the natural consequences and real life circumstances are present. Consider a situation in which bath time is problematic for a child and family. The family bathes the child in the evening, which can be a challenging time to schedule a home visit. If, however, the practitioner request the family to bathe the child at a different time of day for his or her convenience, then the family may be willing to do so, but the energy level of the child and family will be different, the amount of time allocated to the activities could vary, the possibility of confusing the child and causing other negative outcomes increases due to changing the schedule, and the challenge of generalizing the strategies and skills to the real -time context will have to be overcome. Practitioners may voice concerns regarding their availability to participate in activity settings or routines that occur outside of an 8:00 a.m. to 5:00 p.m. workday due to personal commitments, family issues or limitations on the number of available visits after 5:00 p.m. (i.e., a practitioner willing or available to provide evening services one night each week).

The nature of early intervention services requires practitioners to be open to alternative scheduling because the lives of children and families do not stop at 5:00 p.m. Learning opportunities exist throughout the child and family’s day, evenings and even weekends. Certainly practitioners are not expected to be present for every bath time or evening meal, but should be available for initial and occasional visits to support the family’s ability to promote the child’s participation during the identified activity settings. Practitioners are often challenged by shifting to this type of scheduling as they begin to implement natural learning environment practices. As a result, they have limited flexible times available because they may have some families blocked at times in which the activity of another family typically occurs. Until the practitioner shifts all children and families on his or her caseload to activity –based- scheduling, he or she will continue to have limited options for meeting individual child and family needs.

Scheduling that includes Bursts of Services
Episodes (or bursts) of care have been discussed as a viable strategy for supporting children with development disabilities and their families in order to match the immediate and ongoing needs with appropriate levels of services (Palisano & Murr, 2009). As part of using a Team Lead approach to teaming, scheduling using a burst of service is used at the beginning of intervention with a newly enrolled child and family (i.e., frontloading) or due to changes in family, child, environmental and practitioner factors. Frontloading is a scheduling strategy that enables the practitioner and care providers to address pressing needs faster than implementing a less frequent approach. For example, a child with a severe feeding challenge (e.g., Losing weight, vomiting, swallowing issues, making the transition to oral feeding) should be seen frequently, especially initially, to address support for all critical people feeding the child and during all meals. A practitioner can use frontloading for a child in multiple environments (e.g., home and child care, grandma’s house and home) to more quickly observe and support the child’s participation across environments, people, and times of day. The practitioner might schedule several visits with the family within the first week or 2 weeks following enrollment instead of starting out with weekly visits.
Teams must consider the long-term view of the child and family when selecting the Team Lead. In some instances, however, the experience of a team member other than the Team Lead may initially and immediately be required in the short term. For example, children with diagnosis of cerebral palsy with quadriplegia often have many assistive technology needs that require the knowledge and expertise of multiple team members. The team members selected as the Team Lead may need intensive support from other team members as specialized equipment needs are identified and the effectiveness of the use of the equipment is assessed across environments. The Team Lead and SSP would implement high frequency joint visits (i.e. burst of service) in this situation to ensure that an initial plan is in the process of being implemented that meets the needs of the Team Lead. SSP, parents and other care providers, and child.

Scheduling a burst of service can also occur when there are changes in family, child, environmental, and practitioners factors. The burst of service is use to support the child and family through substantial changes that could disrupt the achievement of child and family outcomes and ameliorate the possible negative effects of life-changing events. For example, family factors to consider for which a burst of service might be appropriate include, but are not limited to, the birth or adoption of a new baby, parental divorce , family illness or death, recent parental diagnosis of mental health issue, parent unavailability (e.g, death, incarceration, abandonment, alcohol or drug abuse), or parental job change or job loss. Child factor changes for consideration include, but are not limited to, developmental growth spurt, regression of skills, new health issue or condition (e.g. diagnosis, surgery) or disruption of a routine due to family or environment change. Changes in environmental factors will affect the entire family unit and should be considered for a burst of service. Environmental factors include the family moving to a new location, transition in child care, the family moving in with an extended family member or vice versa, homelessness, or the family community experiencing a natural disaster. Practitioner factors changes can also be a good time for a burst of service. For example, if a practitioner serving as Team Lead leaves the team, then the new Team Lead and family should consider a burst of service as a means for a quickly getting to know one another and decreasing any possible negative effect the change in provider might have on the child and family. Depending on the circumstance or issue, a joint visit may be part of the burst of service because of the need for specialized expertise and knowledge. Appendix 5E contains two documents (Appendix 5E1 and Appendix 5E2 ) that depict an example of the caseload of an OT working full time in an early intervention program and the current month’s calendar of her schedule. These documents are provided to share an example of FAB scheduling. The caseload list provides the total number of children and families a practitioner’s ongoing caseload and delineates her other responsibilities, which include evaluations, IFSP meetings, and joint visits (for children on her caseload as well as not on her caseload), and team meetings. The calendar shows the variations in the time of day of the visits as well as when visits are scheduled in the child care center (CCC) in order for the OT to participate in previously identified activity settings that occur at that time for a child and family/child care provider. Joint visits (JV) are also noted on the calendar as well as the discipline of the other team member participating in the joint visit. The calendar also indicates the visits that require an interpreter’s participation (Intrep), which may affect FAB scheduling. The calendar indicates 11 visits for the Donovan family as part of frontloading as a burst of service following the child’s IFSP meeting that occurred at the end of the previous month. Making the transition to FAB scheduling can be one of the most challenging aspects of implementing a Team Lead approach to teaming. This approach to scheduling vastly differs from more traditional block scheduling and practitioners’ unfamiliarity with the strategies and perceived ambiguity with visit to visit scheduling can create anxiety and an initial feeling of loss of control over one’s own scheduling. As well, administrators may find new challenges for tracking caseload numbers because practitioner’s schedules may no longer reveal obvious openings, which is why caseload maximums are determined by team rather than individual (see chapter 3). Fab scheduling, although new to many practitioners, offer maximum flexibility and alignment with natural learning environments practices. Once all team members have shifted their entire caseloads to this type of scheduling, the practitioners and families find it more helpful and flexible and a different type of sense of control of the schedule develops over time.

Excerpted from: Shelden, M'Lisa L., and Dathan D. Rush. "Frequency and Intensity of Service." The Early Intervention Teaming Handbook: The Primary Service Provider Approach. Baltimore: Paul H. Brookes Pub., 2013.. Print. We have replaced the term Primary Service Provider with Team Lead for consistency with Arizona’s Policies and Procedures.