Improving Quality Practices in Early Intervention:

1. Improving Quality Practices in Early Intervention: Missouri’s IFSP Quality Rating Scale

2. Agenda • History / Tie to State Improvement Plan • Description of IFSP Quality Indicators Rating Scale (QIRS) • Development & implementation • Selecting & Reviewing IFSPs • Preliminary Results of Review • Plans for the future

3. SICC-Identified Needs in First Steps • SICC meetings from 3/03 – 1/04 identified a number of priorities for improvement: • A system of accountability/oversight to ensure high quality, family centered services • Provider availability and training • Financial/budgetary concerns (cost-containment) • Overall concerns about the quality of services & appropriateness of IFSPs

4. Legislative/State Concerns • Program costs increasing • Variation in cost per child • Limited support/guidance to ensure quality services • Need cost containment without compromising quality

5. OSEP Influences • Missouri needs a system of accountability • Service coordination concerns • Monitoring SPOEs to ensure quality

6. Missouri’s Improvement Planning • Stakeholder meeting with NECTAC • June 28-29, 2004 • Understand challenges related to increasing service costs, appropriate provision of services, implementation of accountability strategies & incentives to change provider practices • Develop an improvement plan to address challenges • June 30 – July 1, 2004 • Develop a “Standard of Practice in Early Intervention” tool • If we know what “bad” IFSPs look like, then what do “good” IFSPs look like?

7. IFSP Quality Indicators Rating Scale (QIRS) • Designed to be used in accountability & monitoring procedures • Specific contractual uses for 3 of 24 System Points of Entry (SPOEs) • Reviewers will rate randomly selected IFSPs on a scale of 1-5 • 1: needs improvement • 3: acceptable • 5: recommended practice

8. IFSP QIRS Development • IFSP document: • Workgroup took sections • Identified required components • Identified poor & quality indicators • Reported initial recommendations to entire stakeholder group; gather consensus • NECTAC left with butcher block paper & a collection of concepts and ideas • NECTAC used stakeholder input to draft QIRS • Missouri stakeholders reviewed and revised

9. IFSP QIRS Development • 8/19/04: National expert reviewed rating scale • 8/23/04: Conference Call with MO stakeholders, NECTAC & national expert • 8/31/04: IFSP Rating Scale finalized • 9/22-23/04: NECTAC provided awareness level training on EI research and the QIRS in St. Louis (videotaped for later statewide use)

10. Developing Guidance • October 13-14, 2004: Develop exemplar for IFSP QIRS • Used IFSP for a child from Virginia • NECTAC provided introduction to developing exemplars; facilitated small group work in this area • November 3, 2004: Internal review of exemplars complete; published to workgroup for review

11. Developing Guidance • Exemplar feedback • very positive about having exemplars • reworked some in-house revisions • clearly requested additional exemplars • Began training SPOEs using scale & exemplar in January 2005

12. Developing QIRS Review Process • Determining Procedures • May 3 & 4, 2005 • NECTAC facilitated stakeholder group in determining process for selecting, reviewing and scoring IFSPs, and providing overall scores and feedback to SPOEs • Requested files from 3 SPOEs to pilot scoring • May 23, 2005 • Piloted scoring – scoring group + Service Coordinators from 2 SPOEs & DMH • May 27, 2005 • Conference call with 3 SPOE Directors regarding procedures

13. Selecting IFSPs for Review • IFSPs are selected up to 10% of SPOE child count (but no more than 50 files) to sample across: • Service Coordinators (DMH & SPOE), • Initial IFSPs (minimum 5, plan for 1/3 of child count), • IFSPs that have gone through review (minimum 5, plan for 2/3), • IFSPs where the child is 2.5 years or greater (minimum 5), and • IFSPs where AT has been identified as necessary (minimum 5).

14. IFSP Scoring • Individual IFSPs are rated on up to 17 areas. • Two areas (Assistive Technology and Review) could be not applicable on a given IFSP. • On the 5 point Likert scale, “2” and “4” are not defined because they represent mid-points. • Each IFSP will get a score of 1, 2, 3, 4, or 5

15. IFSP Scoring Table

16. SPOE Scoring • Each SPOE is rated on overall percentage of IFSPs scored as high quality, quality, acceptable, needs improvement, poor. • SPOEs receive a Summary Report listing the number of files receiving each score. • IFSP scores are averaged and the SPOE receives a rating based on their average IFSP score: • High Quality = 4.5 – 5.0 • Quality = 4.0 – 4.4 • Acceptable = 3.0 – 3.9 • Needs Improvement = 2.0 – 2.9 • Poor = 1.0 – 1.9

17. Reviewing IFSPs • Each IFSP was evaluated independently by 2 reviewers • Reviewers discussed use of the Rating Scale to ensure consistency • If scores resulted in the same quality range (quality, acceptable, poor, etc.), file complete • If scores in different quality ranges (quality & acceptable; poor & needs improvement), reviewers met and came to consensus on score

18. Preliminary Results • 1 of 3 SPOEs met “Acceptable” or higher • IFSPs varied from high quality to poor • IFSPs varied within the documents • Service Coordinators seem to have areas of expertise • General documentation / completion • Use of “stock phrases” that don’t change (transition) • Writing parent comments verbatim/no probing • Lack of tie between family’s concerns, priorities & resources and services

19. Preliminary Results • 3 SPOEs average cost per child:

20. Future Plans • Lead Agency and First Steps Consultants will meet: • Dec 20, 2005: Train LA & FS Consultants on QIRS review process • TBD: Review QIRS results to determine statewide and regional training needs • TBD: Develop & provide training • Jan/Feb 2006: Embed into service coordinator training for 8 new SPOEs

21. Future Plans • Lead Agency and First Steps Consultants will meet to: • TBD: With TA from NECTAC, evaluate and revise (if needed) QIRS tool and process • TBD: Training additional reviewers for future statewide QIRS implementation • TBD: Institutionalize the QIRS reviews as part of the monitoring & accountability process