Partnering for Change: Stakeholder Alliance Symposium

Introduction

On July 2nd, 2008 a widely diverse group with a common concern came together to discuss a participatory action research project that we are calling “Partnering for Change”. This group was composed of families, educators, researchers, service providers and representatives from school boards, Community Care Access Centres, provider agencies, Ontario Ministries of Education, Children and Youth Services, and Health and Long-Term Care concerned about the challenges faced by school-aged children who have coordination problems.

Collectively, we share a belief in the need for change in the way School Health Support Services (in particular, occupational therapy (OT) services) are delivered and funded across Ontario; however, there is not yet evidence or consensus about the best way to proceed. The varied perspectives that each participant brings as a stakeholder are critical to the success of this project in which we will test a different model of OT service delivery and gather evidence about its effectiveness.

As a first step in developing a partnership among stakeholders, the purpose of this Symposium was to:

• Become familiar with the proposed service delivery model and the timelines of the research project(s);
  
• Appreciate the perspectives of a broad range of stakeholders and discuss mechanisms for participation and input throughout the demonstration project.
  

Background materials were distributed to participants in advance of the Symposium.

List of participants

Twenty-eight stakeholders were able to join us for this meeting. 

Meeting Report: Summary of Key Points

We began the meeting by setting the context for the morning with an overview of the assumptions inherent to this project (see Appendix 3) and a presentation by Dr. Missiuna outlining the needs of children with coordination challenges, the difficulties underlying the current model of service delivery, and the opportunities for change. Dr. Missiuna also reviewed the timeline of the research projects as dictated by the two funding sources.

In small groups, participants discussed the following questions, and brought their synopsis to the group as a whole.

1. What perspectives are represented in this partnership?

Participants appreciated that the parent/consumer, service provider, teacher, decision-maker, school board administration, researcher/academic, funder, provincial representative and policy-maker perspectives were among the many points of view in this partnership.

Participants expressed a shared commitment to:

• Recognize the need for a change in the service delivery model
  
• Maintain an open mind and an open perspective with respect to the way in which change might take place
  
• Improve children’s function and participation
  
• Build teacher and parent capacity
  
• Pool our collective knowledge
  
• Work as part of a team that includes all of the important people in the child’s environment
  
• Build relationships amongst team members to facilitate communication and trust
  
• Link home, school and community environments
  
• Consider the needs of parents in developing this new service delivery model
  
• Use our awareness of potential barriers and operational issues to strengthen the development of this project
  

Participants recognized a shared understanding of:

• The excellent timing of this project with respect to the current climate of change in the education and healthcare systems
  
• The need to assume a developmental and preventative perspective (health promotion), given the chronic nature of coordination challenges
  
• The professional skill set that will be needed for this model to be successful
  
• Operational issues such as cost-benefit ratios and resource allocation
  
• The practical workings of schools and school boards
  
• Teacher job requirements and learning styles
  
• The need to cultivate an effective partnering relationship between the OT and teachers, rather than simply adding to teacher workload
  
• The importance of providing information that is geared towards parent needs and capacities
  
• The importance placed upon student achievement within the education system
  
• The complexity of the existing system and the need to reduce this complexity to improve parent navigation through the system
  
• The importance of establishing good relationships with parents and teachers
  
• The limitations of the current model
  
• The potential barriers inherent to changing this service delivery model
  
• The fact that funding often drives clinical practice
  

2. What potential issues or challenges can be anticipated as we move forward with this project?

Participants recognized that it will be important to be aware of several issues as this project is implemented. For instance, it was acknowledged that the lack of time to build solid relationships may be contributing to issues within the current consultation and therefore cultivating the relationship between the OT and teachers in the new model will be central to its effectiveness. Personnel issues such as teacher unions might also impact implementation. There is often a high teacher turnover rate in schools, which may be an issue for sustainability. Procedural issues including PHIPPA regulations impacting privacy and consent may also be relevant. Challenges around consent and privacy issues may be helped by cultivating good relationships and clear communication with parents. Participants recognized that each school has its own environment and culture, and that it may be important to begin this pilot project in a school that has a stable staff and a culture that embraces new learning and use of evidence.

School Health Support Services (SHSS) have traditionally been framed by a medical model which has never fit well for OT service delivery or for the delivery of services in an educational setting. In moving away from the medical model towards an educational model, we need to recognize the challenges inherent in this change, given that the medical model is prevalent in society and people are familiar with it.

In terms of translating knowledge to teachers, participants raised the issue of which population would be most relevant to target: Special Education Resource Teachers as well as classroom teachers and psychoeducational consultants. Participants also suggested that knowledge translation efforts could be targeted to pre-service teacher training (i.e. college) but that there would be a lengthy time process involved in effecting this change.

Participants recognized that the OT will need to be sensitive to children’s feelings when working with them in the classroom so they are not singled out from their peers. The OT will need to act as a coach and resource person for teachers. For example, CAS workers are currently building relationships with school staff in at-risk schools; perhaps we could look to this model for suggestions.

3. If we look 3 years down the road to when the project is completed: how will we know it was a success? * indicates a potentially measurable outcome

a. Child-level indicators:

• needs are identified earlier*
  
• greater feelings of acceptance*
  
• diminished feelings of isolation*
  
• enhanced success and achievement in later grades*
  
• improved mental health/social functioning/self-concept*
  
• greater participate in the classroom
  

b. Family-level indicators:

• parents report that their children’s needs are being met in the school system*
  
• parents have enhanced knowledge and capacity to meet their child’s needs at home and are aware of strategies to implement*
  
• families are considered as part of the team and are respected and empowered
  
• parents are better prepared to be advocates for their children
  
• parents have an enhanced understanding of the long-term issues and secondary problems related to DCD*
  

c. Teacher-level indicators:

• increased skills, competence, confidence, and satisfaction*
  
• ability to transfer and generalize their knowledge with respect to strategies for managing coordination difficulties to other children in subsequent classes
  
• increased ‘bag of tricks’ in terms of more tools and strategies*
  
• increased teacher capacity and knowledge with respect to coordination challenges*
  
• greater understanding of typical and atypical motor development*
  
• better able to recognize the ‘red flags’ that suggest coordination challenges*
  
• better able to advocate for children with DCD*
  
• increased understanding of the importance of participation and function for these children*
  

d. OT-level indicators:

• viewed as an integral part of the school team and are seen as educators and mentors*
  
• development of effective collaborative relationships with teachers*
  
• opportunities to provide services in different ways (e.g. opportunities to provide keyboarding groups, to be present at parent-teacher nights, etc)*
  
• necessary supports in place to undertake home visits*
  

e. System-level indicators

• waitlists for OT services are decreased*
  
• children who need these services are receiving them
  
• there is an increased level of achievement for the whole school on the EQAO*
  
• the model is sustainable
  
• PHIPPA is modified to include the circle of care in an education system
  
• system barriers are reduced across Ministries
  
• information about the child’s needs follows him/her seamlessly through the system
  
• there is a different funding model for OT services*
  
• there is a de-emphasis on the medical model and the need for diagnosis prior to carrying out actions
  
• there is a seamless circle of care which includes everyone in the child’s environment
  
• teacher training is modified to include education related to this population*
  

4. What are the next steps?

At the meeting, several participants identified their individual willingness to be involved during the pilot and demonstration stages of this project and to assist in determining the measures that will be used in evaluating the effectiveness of this model.

Please contact Danielle at levacde@mcmaster.ca or by voicemail at (905) 525-9140 ext. 21458 with questions pertaining to opportunities for involvement or to further detail your potential participation in these projects.

We would like to seek the participation and input of stakeholders who were not able to attend this meeting. If you were not in attendance, please feel free to forward your comments or questions to Danielle. We look forward to including many more stakeholders at the second symposium, in February 2009, at which we will discuss preliminary findings and next steps. We will disseminate the date and times for the second Symposium well in advance.

Thank you for contributing your time to this exciting initiative. We look forward to continuing our partnership as we move forward with this project!

Introduction

This symposium took place as part of a participatory action research project that is designed to bring together stakeholders from across the province to examine the feasibility of an innovative model of delivery of occupational therapy services in schools. This project involves stakeholders from the CCACs, Ministry of Health, Special Education, MCYS, service providers, teachers and families. The project was originally designed to test whether, by working right in classrooms, it would be possible for occupational therapists (OTs) to enhance the capacity of teachers to manage the 5% of children in every classroom who struggle every day to perform basic motor tasks .

Participants

Thirty stakeholders were able to join us for this meeting. Please see Appendix 1 for a list of all 49 stakeholders, including those stakeholders who are participating in this project but were unable to attend this meeting.

Meeting Report: Summary of Key Points

We began the meeting with a presentation by Dr. Missiuna summarizing the overarching goals of the project and the timelines for pilot and demonstration projects. Dr. Missiuna also reviewed what has transpired since the symposium in the summer. Briefly, Halton District School Board agreed to participate in the pilot project, two occupational therapists were hired, ethical approval was received, specific schools were recruited, teacher and family involvement was solicited, data collection methods and consent process were trialed, educational materials and teaching sessions were developed, and professional videotaping of children with and without Developmental Coordination Disorder in classroom settings were completed. Since October, two occupational therapists have been working within this model of service delivery at Hawthorne Village Public School (large school, high growth area, 2 days per week) and at Oakwood Public School (smaller school, many sociodemographic challenges, 1 day per week).

In order to highlight for the stakeholders some of the strengths and challenges that have been encountered, Nancy Pollock and Sandra Sahagian Whalen, the occupational therapists who have been working at Oakwood and Hawthorne Village shared some stories. One of the main objectives of this project is to focus on earlier identification of children who are struggling and to intervene and support them while they are young; therefore, most of the stories focus on children in younger grades.

Story # 1 (OT 1)

I am working within a JK/SK classroom with a very experienced, skilled and creative teacher. As part of their literacy activities, they typically work on the letter of the day. After the full group lesson, children go to centres and, typically, one centre involves some type of printing activity. The teacher often used large diameter bingo markers and large strips of blank paper for printing practice. The children were copying the letter from an easel not easily viewed from the centres.

I spoke to her briefly at recess about the idea of using very small pieces of crayon to encourage finger differentiation, pinch grasp and more control of the writing implement. I also suggested giving more visual structure to guide them in copying the letter and using a vertical surface to position the hand and wrist correctly. The teacher said she had always thought bigger was better in terms of easier grasp, so we talked about the developmental steps of preparing the hand to grasp a pencil and though the large diameter is easier to grasp in the moment, it doesn’t move the children along to a more mature grasp pattern.

The next week when I was back in, the teacher had made a new activity for the letter of the day with little Mini M books, with an M to copy, and she had cut pencils so they were using little short pieces. She had also set up a vertical station as one of the centres with paper held on by a magnet at the easel. It was great to see such uptake in a very quick time frame!

Story # 2

Working within the same JK/SK class, the teacher had identified three boys she wanted me to specifically watch. My first impression was that all three boys were significantly delayed in their motor development as seen in their skills when using scissors, crayons, opening lunch containers etc. I am in the school 1 day a week so, over the next two weeks, I participated in the centres for one period each time, and did some direct teaching with the boys about holding and using scissors, opening juice boxes and water bottles and some printing in sand and shaving cream. Two of the three boys responded quite quickly with this approach and after three weeks both the teacher and I were able to see substantial progress. The third boy did not respond to the strategies to the same degree and continued to struggle. The two boys who responded were in JK; one came to school with no prior experience and, according to the teacher, parents treat him as if he was a toddler, e.g. carry him, dress him etc. The second boy is a recent immigrant who has little English and was less familiar with classroom activities. The third, the “non responder”, is an SK child who has intermittent school attendance and family issues but likely has motor concerns as well. It was interesting to see how similar these children looked on first observation and then how quickly their response to intervention discriminated between them. One issue that I’ve struggled with is how to document this type of small group experience – our OT college doesn’t really have a method that would work well for seeking informed consent or documentation when we are really just doing these kinds of brief screening and strategy trials.

Story # 3 (OT in large school)

Over a two day period in November I had the chance to visit a variety of classrooms in grades from kindergarten through grade 6. Many of the teachers mentioned they had several students who stood at their desks, rather than sat; or were constantly wiggling and shifting in their chairs. Upon observation I noticed many of the smaller kindergarten students’ feet did not touch the floor when seated at the classroom tables. In one grade 3 class, I noticed that many of the students were sitting on the edge of their chairs, with the chairs tipped forward so the back legs were off the floor. When asked to sit back in their chairs, I noticed several students could not touch the floor with their feet. When chairs were pulled up to their desks, I saw a lot of shoulders hiking up in order for children to reach the top of the desks. When I questioned the teacher regarding the apparent problem with the size/fit of the desks and chairs, she responded that the furniture was delivered with the portable and she had no idea what grade had been in the portable previously.

Later the same day, I had visited a grade 6 classroom. The first thing I noticed in this classroom was that many of the students were hunched over their desks when working and some of the students’ knees were bumping the shelf under the desk. I asked the teacher about the size of the desks and she reported that her classroom had previously been a grade 4 class and the furniture had never been changed.

A visit to a grade 2 class the next day revealed a classroom of varying sizes and heights of students, but desks and chairs that were all the same size. Several students were standing to work as the desks were too high, or tipping their chairs forward to allow their feet to touch the ground. The teacher pointed out other children whom she thought may have motor problems as they constantly moved and wiggled in their chairs. I proceeded to measure the desks and chairs and recommended for a couple of students that the desks be lowered by 2 inches (fortunately, they were adjustable) and that smaller chairs be found for these students. Upon follow up about a month later, the teacher told me the changes had made a huge difference, with those students now less “wiggly and jiggly” when at their desks. They were able to attend and to concentrate much better.

I had a chance to speak with the principal and 2 VP’s about these observations about poorly fitting classroom furniture. One VP expressed immediate concern about the safety issue of students rocking forward so their feet could touch the ground; the principal identified lack of staff knowledge regarding appropriate furniture height/fit, as well as a custodial issue around the moving of furniture between classrooms, between classrooms and portables, and adjusting of table/desk heights when the furniture is adjustable. A full staff training session is planned around posture/positioning and conducting a classroom desk audit.

Story #4

Almost immediately upon my arrival in October, a kindergarten teacher asked me to observe a few students about whom she had motor concerns. Due to the number of kindergarten classes at this school, her classroom is not in a regular kindergarten room, requiring the use of hall lockers, leaving the room to use the bathroom and a smaller classroom space in which to deliver the program. I spent one period participating in her classroom program, observing the students of concern. 

One JK student, a boy, stood out immediately- I noticed:

• a very floppy and awkward gait as he moved about the classroom
  
• difficulty negotiating around peer/objects in the classroom- apparently unaware of his body position in space
  
• a pencil grasp typically seen in children with low muscle tone and not on the developmental sequence of typical grasp development; hypermobile finger joints
  
• “flopping” to the floor at transition times, requiring 1:1 attention from the teacher to redirect and reengage
  
• needing help to open his containers at lunch time
  

I flagged this student for this study, and the family provided consent for participation. Follow up visits yielded further information, including:

• great difficulty staying seated on the carpet- “I’m too tired”- constantly shifting, moving, lying on floor, fiddling with hands, fingers and objects within reach
  
• need for step by step assistance to organize and execute every step of an activity, including dressing/undressing at his locker and pulling up pants after using the bathroom
  
• difficulty standing in line- often wandering away
  
• ongoing difficulty with transitions and regulating his behaviour in the afternoons
  

I recommended several strategies to the teacher and SERT with some success being achieved, including the use of a visual schedule for the locker routine and bathroom routine, a mat on floor to define his space, as well as the option to lean against the wall for postural support, movement breaks, calming/relaxing music at the listening centre and some fine motor activities to develop hand skills required for pencil control. I reviewed my observations and recommended strategies with the mother in January by telephone and was told by the teacher that a pediatrician appointment was coming up. Following the call, I summarized my observations and the strategies in writing. I met with the teacher and VP (SERT was unable to attend) to review the information I had discussed with the mother, and to review my written summary prior to sending it home to the parents. The school raised concerns about this type of information (observation of motor performance) going home to the parent and expressed some discomfort with this process. This method of communicating observations that were made by a health professional seemed to be unfamiliar for the school.

In small groups, participants then discussed the information provided about the study and their reactions to the stories. In particular, questions were posed about the issues or concerns that each story raised and what the implications of each issue might be, at a systems level.

Summary of Group Discussion

The notes taken in the small groups and the plenary session in the early afternoon highlighted the many successes and challenges seen thus far in the project. The successes are, for the most part, at the direct, interactional level among teachers, the OTs and the parents. Most of the challenges appear to be at the structural or systemic level.

Some of the specific ideas raised by the stakeholders are outlined below:

Successes

• High degree of acceptance of the OTs into the school and in to specific classrooms. Teachers have been very welcoming and interested in participating.
  
• We have seen multiple examples of very quick uptake of suggestions and strategies by the teachers
  
• Many of the suggestions the OTs can make are very simple, practical and easy to accomplish quickly, e.g., changes to seating, alternate types of paper, visual schedules, altered verbal cueing, changes to writing tools.
  
• Teachers have been keen to attend educational/inservice sessions and have commented on how helpful they have found the information
  
• A parent workshop was held and many parents are in ongoing communication with the OT
  
• Several teachers have recognized that the ideas the OT is bringing would be helpful for all the students in their classrooms, so the emphasis has shifted to one of promoting development versus intervention with specific children.
• OTs have had the chance to teach whole classes on topics such as scissor skills, preparing your bodies and hands for desk work, printing and cursive writing. The teachers have been able to observe and model from these classes.
• We have been able to develop resources and in-services in response to teacher requests with short turn around time
  
• Teachers have commented on the value of the different perspective the OT brings and that the information helps to round out their view of the student
  
• The OT has been able to contribute information and observations to team meetings about children identified with concerns
  
• Information has been shared with parents to support them in accessing health care services
  
• The opportunity to see the children over time has been very helpful to see their response to intervention
  
• The opportunity to be in the school consistently allows for the chance to try, adapt, adjust strategies easily and to follow-up quickly
  
• Being right in the classroom allows the OT to immediately seize on opportunities to embed things into the program
  
• The “intervention” is all happening in the child’s natural environment so there is no issue about transfer or generalization
  
• Teachers are very tuned in to the children who are struggling and have appreciated the confirmation from the OT that they are able to identify these children
  
• There is a sense that this model could be effective with many other students beyond those with coordination difficulties
  
• The OTs have been invited to participate in School Board wide discussions around the kindergarten program and to contribute to the development of indicators for the JK/SK curriculum.
  

Challenges

• Teachers have limited background in motor development and the typical progression of skills in young children. Much discussion centred on pre-service education and the limited focus on development and special education within these programs.
  
• Curriculum pressures, particularly in literacy and numeracy are very high for teachers and they feel that they don’t have time to address some of the foundational developmental skills
  
• Physical plant issues are present (e.g., incorrect sizes of chairs and desks) but limited opportunity to change these or move them around without major disruption or impinging on union or other regulations (e.g., inability to have children dress in the hall on a bench when the cubby area is too congested due to fire regulations)
  
• Maintaining communication with families can be challenging and finding opportunities to provide knowledge to the parents can be difficult for example, when they are working and not able to come to the school, when language barriers and/or socio-economic stresses are present.
  
• Differing rules and regulations between the health care system and the educational system can cause conflicts, and block communication, e.g., specific issues such as access to the OSR, participation in school team meetings, documentation requirements by the OT college, consent issues.
  
• OTs who have worked in a more traditional model of one-to-one service delivery may find it difficult to move to this model and require quite a bit of support
  
• Parent advocacy for children with coordination difficulties is not easy as there are no parent groups available and often the parents are unaware of the nature of the child’s difficulty
  
• Funding for this type of model outside of the current project is a question. The current model (SHHS) is funded by Ministry of Health, but currently under review. What is the role of Ministry of Education, Ministry of Children and Youth?
  
• Development of outcome indicators and evidence as we move from pilot to the demonstration project. What are the specific indicators of success? Different audiences will likely be interested in different indicators.
  

What are the next steps?

• Continue pilot involvement until end of 2008-09 school year as new learning is still taking place
  
• Conduct focus groups with participating teachers to solicit feedback and suggestions
  
• Recruit and begin training OTs for demonstration project
  
• Determine participating schools for 2009-10 school year
  
• Develop relationship with, and seek permission to engage, a second schoolboard for the demonstration project
  
• Continue to develop resource materials, lunch and learns, and centre-based activities
  
• Determine outcome measures for demonstration project
  
• Resubmit demonstration project methods and measures to McMaster Research Ethics Board and ethics boards of both schoolboards
  
• Address issues around consent, access to information and documentation in collaboration with OT College and School board
  
• Support parents in beginning to develop a virtual network
  
• Consider other potential stakeholders to add to the group
  

How can you help?

Share these stories and the issues that were raised for you with the individuals whose perspectives you represent. Send any additional thoughts or suggestions that arise within your stakeholder constituency.

Let us know if you have an interest in working on any more broad, or system level, issue that might have been raised.

Help us to become aware of other initiatives that may impact on this study, similar work going on in other jurisdictions, or resources that may be supportive.

Acknowledgements:

The team is grateful for the Ontario Rehabilitation Research Advisory Network/Ontario Neurotrauma Foundation grant that funded this pilot study. Funding for the demonstration project is being provided by Canadian Institutes of Health Research.

For more information about the progress of this study, or to share information, please contact our Project Coordinator, Cindy DeCola at decolac@mcmaster.ca or 905-525-9140 ext. 26074

Cheryl Missiuna presented an update on the pilot and demonstration phases of the study. For details on the pilot study results and the demonstration project prior to November 2009, please download our Stakeholder Newsletter.

The study is currently in the Demonstration Phase of the project (September 2009-June 2010)

• 8 Occupational Therapists (OTs) are now working in 11 schools in 2 school boards enhancing teacher and parent capacity
  
• OTs in classroom as a “coach” to the teacher (focus on JK to Grade 3)
  
• OTs facilitating early identification and screening
  
• OTs providing strategies/suggestions/information to teachers
  
• OTs sharing information with parents of children who have motor coordination challenges
  

Themes arising thus far from Teachers, Administration and Parents of participating schools were presented:

• Community capacity is being enhanced
  
• Parents and teachers are more involved
  
• Teachers feel comfortable and empowered to speak to parents
  
• Early intervention helps
  
• “Little things” make a big difference
  
• Improved student achievement has been noted
  
• Identifying motor challenges changes teacher perception
  
• Educators from pilot school implemented suggestions in second year
  
• Schools are pleased with OT support to teachers, students and parents
  

Themes arising from OTs delivering this model

• Enhanced capacity of school in second year
  
• Connecting with parents on a regular basis
  
• Enhancing capacity of teachers and students
  
• OTs excited about the success they are seeing in the schools
  

The Demonstration study will continue until the end of the school year (June 2010). In the Fall of 2010, we will connect with participating teachers and parents to see if capacity has been enhanced. Symposium 4 will take place in the late Fall to share the study results and outcomes with Stakeholders.

We welcome the participation of all stakeholders in this symposium in order to determine how we can best maintain the positive momentum of this project.

Driving and restraining forces

Based on a concurrent breakout group activity, groups were asked to identify environmental factors that would facilitate uptake of the Partnering for Change model and the forces that might potentially prevent the model from being rolled out provincially.

Forces Driving Current Uptake of Research Findings …

• Model is successful
  
• Positive feedback from participants and stakeholders
  
• Advocacy of parents and teachers who have experienced and liked model
  
• Increasing awareness of parents about Developmental Coordination Disorder (DCD) and about what is possible
  
• Funding available
  
• Local partnerships
  
• Mental health advocacy groups (recognizing the secondary mental health issues)
  
• Networking in community
  
• Review of School Health Support Services (SHSS) is underway
  
• Useful existing relationships with stakeholders
  
• Movement towards action research
  

Restraining forces …

• Lack of funding
  
• Ministry policies and procedures
  
• College of Occupational Therapists of Ontario (COTO) standards
  
• Potential teacher resistance?
  
• Low priority of government on children’s issues, policy focus on seniors
  
• Competing interests and demands on teachers
  
• Lack of coordination between government ministries
  
• Little multidisciplinary involvement, disciplines working in isolation
  
• Demographic variations across province (e.g. urban vs. rural)
  

Partnering for change in 2013

This was a visioning activity where each stakeholder wrote headlines that they would like to see appearing in newspapers on March 4, 2013. Headlines were then clustered into themes. Participants were able to write more than one headline.

Provincial Scope

• Ministries of health and education deliver ot in ontario schools
  
• Progressive evidence based model used across the province
  
• Canchild research program an efficient and effective model
  
• Ministry implements occupational therapists (ots) in classrooms across ontario
  
• Partnering for change study adopted province wide
  
• Partnering for change a universal model of school/healthcare partnerships
  
• Pfc a leading cutting edge delivery model for health services in schools
  
• Province-wide adoption of new model for school health support services
  

Successful outcomes

• Collaborative approach creates success for children at school
  
• “i knew i could”
  
• All students succeed in halton
  
• Small changes make a big difference
  
• Happy children, classrooms, communities lead to better society
  
• Children have more positive outlook through partnering for change
  
• Children making incredible gains due to new project run in ontario
  
• Team work pays off for children with motor challenges
  
• Partnerships lead to improved lives for children with coordination issues
  
• Children once lost now found – and doing great!
  
• Student achievement soars with ot support
  
• Decline in adolescent depression linked to new delivery model
  
• Child once diagnosed with dcd brings home olympic gold!
  

Stakeholder engagement

• Teachers partnering with ots teach students new ways to achieve success
  
• School boards with ots in classroom performing better
  
• Teachers empowered to adapt strategies in classroom
  
• Ots recognized for their hard work and benefits in education
  
• Parents love the help their children receive at school
  
• New training program in motor development in teacher college curriculum
  
• Ots enhancing children’s capacity in the classroom
  
• Partnering for change now part of teacher’s inservice experience
  
• Parents empowered to implement strategies in various settings
  
• Support services help teachers provide education
  
• Ontario teachers trained on maximizing potential of special needs kidswait lists down and satisfaction up in shss
  
• Partnerships between education and health help kids succeed at school
  
• Teachers thankful for great ideas that help their students
  
• Interprofessional teams in place in all schools in ontario
  

Sustainability

• Cutting edge partnering for change program receives ongoing funding
  
• Government rolling out more customized support for students
  
• Ministry of health (moh) funds new model for delivery of ot services to schools
  
• Early identification and intervention in place
  
• Final barriers removed to children accessing needed supports
  
• Multi-level services available as appropriate for child’s needs
  
• Ministry announces province-wide funding for ot services in schools
  
• Ccac funding for ot and speech language pathology (slp) services given to school boards
  
• Solid structures for sustainability of pfc program implemented
  

Suggested initiatives

Based on a concurrent structured brainstorming activity, ideas were generated on a free-response basis as suggestions of initiatives that might contribute to the sustainability of the project. Participants then individually allocated “votes” to each of the priority initiatives.

• Measure and report outcomes of model (30 votes)
  
• Involve faculties of education and professional bodies (26 votes)
  
• Review and change Ontario funding models (20 votes)
  
• Provide sustainable and stable funding for SHSS (15 votes)
  
• Multiple ministry support (15 votes)
  
• Targeted funding for model (15 votes)
  
• Broaden to include other professionals e.g. Speech Language Pathologists (SLPs), Physiotherapists (PTs) (15 votes)
  
• Tie to move to JK/SK (11 votes)
  
• Make children a priority (10 votes)
  
• Social marketing campaign to increase awareness (10 votes)
  
• Funding from MOH (9 votes)
  
• Provide input to SHSS review (7 votes)
  
• Measure cost benefit (7 votes)
  
• General public education (8 votes)
  
• Leverage Early Learning program (7 votes)
  
• Government lobbying (6 votes)
  
• Increase physician awareness of DCD (5 votes)
  
• Advocate for inter-ministerial cooperation (5 votes)
  
• Highlight this model as “best practice” (5 votes)
  
• Evidence-based model (6 votes)
  
• Leadership (5 votes)
  
• Public awareness (4 votes)
  
• Integrate across age groups and transitions (4 votes)
  
• Knowledge translation strategies (8 votes)
  
• Collaboration around curriculum development (4 votes)
  
• Expand to include other diagnoses (4 votes)
  
• Interdisciplinary collaboration (4 votes)
  
• Increase teacher training (5 votes)
  
• Increase OT training (5 votes)
  
• Tie project to government priorities (3 votes)
  
• Articles in Ontario College of Teachers and OT publications (3 votes)
  
• Funding from Ministry of Education (3 votes)
  
• Emphasize health promotion vs. medical model (3 votes)
  
• Share with parent community (3 votes)
  
• Parents appeal for funding from ministries (2 votes)
  
• Multiple partnerships – health, educ., social services, MOH (2 votes)
  
• Share knowledge nationally and internationally (2 votes)
  
• Involve faculties of education (2 votes)
  
• Identify key gaps in existing Service Delivery (SD) models (2 votes)
  
• Work with COTO to ensure alignment with rules and regulations (2 votes)
  
• Support throughout the year (2 votes)
  
• Parent outreach (2 votes)
  
• Increase OT awareness of classroom issues (1 vote)
  
• Strategically identify decision makers (1 vote)
  
• Collect student voices as outcome (1 vote)
  
• Child and family-centred approach (1 vote)
  
• Approach other boards
  

Breakout group reports

Topics were identified based upon stakeholder feedback about the early findings and the themes that emerged from the first few activities. Participants then self-selected working groups.

Funding

1. Cost-benefit analysis

• Evidence-based funding
  
• Stable
  
• Effectiveness/best outcomes
  
• Value for your dollar, system, person
  

2. Review and change current funding models

• Currently no dedicated funding along lines
  
• CCACs need to change process
  
• Change service delivery models
  
• Waitlist strategies – especially OT and SLP
  
• Move away from fee-for-service model
  
• Collaborative funding model with three Ministries involved
  

3. Sustainable funding

• Protected funding for SHSS
  
• Targeted funding
  
• Multi-year funding
  
• Cannot plan for future until funding is secured
  

4. Equitable access to funding

• Public and Private
  
• Home school
  

Discussion

• Need to move away from fee-for-service model in order to retain good health professionals
  
• Motivation in fee-for-service is to see more kids and this does not emphasize quality
  

Increase Awareness

Target Groups

• MDs, educators, general public, Ministries (Education, Health, MCYS), psychologists, physiotherapists, SLPs
  
• American Psychiatric Association: Need to keep DCD in Diagnostic and Statistical Manual on Mental Disorders V (DSM V)
  

Strategies

• Support strong parent advocacy groups
  
• Teacher and health care professional education
  
• Public education
  
• Workshops
  
• On-line resources
  
• Handouts/brochures for MD offices, schools, public health, Early Learning Centres
  
• Other groups e.g. Autism (ASD), Attention Deficit Hyperactivity Disorder (ADHD) have more awareness, perhaps because more visible in class – need to emphasize why we are concerned about DCD
  

Discussion

• Important to flag kids with DCD early to target secondary issues (obesity, depression, etc.)
  
• Focus on function in the classroom environment, rather than on diagnosis
  
• Emphasize that very small changes can make a huge difference in the long term
  
• Increase awareness to parents that they are not alone in this and can advocate for their children
  

Educate

Who

• Policy makers, medical professionals, parents, public, teachers, EAs, student teachers, OT students, existing OTs, early childhood educators, unions, COTO, advisory groups, CCACs, children
  

How

• Media campaign to create awareness among public and policy makers
  
• Educate on location of resources (websites, research, articles)
  
• Sustain education needs
  
• Empowering teachers vs. fixing kids
  
• Consolidate resources/revamp for other sources
  
• Student OTs link practice i.e. DCD, ASD with school boards
  
• Continuing education board in-services
  
• Lunch and learns
  
• After school sessions for parents and teachers
  
• Integrate links to school board websites, parent council newsletter
  

Discussion

• The process and the PFC service delivery model could be used for any issue in the school, not just DCD
  
• Media campaigns need to run each year – need to keep the buzz going
  
• Competing with other disorders, need to address functioning on a broad level
  
• Educate using a robust website, i.e. CanChild’s website
  
• Cost benefit – huge benefits for a small cost intervention
  

Advocacy

1. Identify what we want to achieve

• Targeted early identification/intervention for kids with DCD
  
• Interventions based on best practices, evidence, cost-effectiveness
  

2. Identify the message

• Unified, consistent message
  
• Alignment with government priorities – e.g. mental health, early years, success for children
  
• What is DCD? What is the impact on quality of life?
  
• What is not working now?
  
• How would targeted plan change things?
  
• Outcomes – what do we want to be moving towards?
  

3. Identify decision makers

• LHINs, MOH, Ministry Of Education (MOE), Ministry of Health Promotion (MHP), Ministry of Child and Youth Services (MCYS)
  

4. Identify advocates

• Parents (key group), teachers, therapists, physicians, psychologists, community agencies, associations
  

5. Identify tools

• Newsletters, articles, internet, existing research, outcomes, public awareness, existing networks
  

Challenges

• In Ontario, only MDs and psychologists can assess and diagnose DCD but many lack awareness
  
• Silos and funding
  
• Parents don’t always have the knowledge to identify that their children have a problem
  
• Need to know existing networks to be able to advocate
  

Multidisciplinary

1. Investigate having a common language

• Having a common understanding and vision (family centred care)
  
• What is success?
  

2. Incremental expansion of Partnering for Change model

• What and who is next?
  
• Building on evidence
  

3. Identifying who all the interdisciplinary members might be

• What unique perspective do people bring?
  

4. Multidisciplinary program at all levels

• Policy, program development, etc.
  
• Need multidisciplinary team
  

5. Multidisciplinary evaluation will be required

Program Integration

Integration has meaning on many levels

• Integration of OT service into schools
  
• Integration of multiple school professions and programs to meet a common goal
  

Infrastructure funding should consider needs of children:

• Unique services for a few
  
• Necessary service for some
  
• Good for all kids
  

Discussion

• The PFC project focuses on the bottom of the pyramid that affects a lot of children, therefore important to move forward
  
• COTO has recognized this type of service delivery as an emerging area of practice and that they are prepared to work supportively to address issues
  

Policy

• Health policy – request for proposal and fee for service needs to change
  
• Individual eligibility needs to move toward population-based approach
  
• Child and Family Services Act (CFSA) needs to be addressed, and the MCYS Act
  
• In Education, Policy/Program Memorandum (PPM) 81 would need to be looked at
  
• PPM 11 – policy around screening, need to look at this in re: early identification
  
• PPM 140 – addresses multidisciplinary supports
  
• Need continued conversations with policy makers and dialogue around our goals vs. their goals
  

Discussion

• Need to determine what the existing specific policies are in the province that are creating barriers and give our suggestions
  

Commitments and expectations

Flip chart exercise. Participants worked in groups, according to their stakeholder role and outlined what they were prepared to give or contribute to the sustainability of the model and what they expected to receive if the model was sustained.

Compelling Evidence – Success Factors and Outcome Indicators 

Participants completed cards individually outlining what they would perceive to be “compelling evidence” of success of the model for their stakeholder group.