By Gabby Hamel
The Help Me Grow (HMG) National Center conducted a year-long Goal Concordant Care (GCC) Study to explore how aligning early childhood system support with families’ goals can not only prevent negative outcomes for young children but also help them thrive. This Study moved beyond the traditional “needs-based” approach to early childhood system-building and focused on understanding and supporting families’ unique goals for their child’s development.
The Study explored how to integrate Goal Concordant Care within the four Core Components of the HMG Model:
- Centralized Access Point: This branch focused on integrating motivational interviewing as a strategy to elicit and document parent goals in the Centralized Access Point with support from the University at Buffalo Motivational Interviewing Center (UBMIC).
- Family & Community Outreach: This branch partnered with Be Strong Families to implement their Parent Café model and support caregivers to identify and seek support for their goals.
- Child Health Care Provider Outreach: This branch was supported by Healthy Outcomes from Positive Experiences, a program of Tufts Medical Center, which provides a framework for asset-driven care. HMG system teams in this branch engaged in training and technical assistance provided by HOPE, and as a result, implemented an intervention both in partner physician offices as well as in the HMG CAP so that HMG staff would be prepared to “close the loop” on referrals related to parent goals.
- Data Collection & Analysis: This branch enlisted the Center for the Study of Public Policy to provide initial training and technical assistance around the Protective Factors Framework.
Each of the strategies deployed across the Core Components, otherwise known as “enhancements”, were designed to provide participants with a full-picture view of how Goal Concordant Care can be integrated into the HMG Model.
Integrating Motivational Interviewing at the Centralized Access Point
The Centralized Access Point (CAP) branch partnered with the UBMIC to integrate motivational interviewing (MI) as a strategy to elicit and document parent goals.
MI is “a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion” (Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (3rd edition). Guilford Press).
HMG Orange County, CA was one of the three participating HMG systems in this Learning Community branch. HMG National spoke with them to get an inside look at how HMG Orange County integrated MI into their work, the challenges they came across during the Study, and the impact this has had on their system’s HMG CAP.
National Center: How did you integrate the MI enhancement into your HMG, including how you support team members?
HMG Orange County: In the initial phases of the project, we sought to determine how to best incorporate all aspects of the project with PDSA cycles and changes in the System for Tracking Access to Services (STAR) data system for tracking data.
In terms of eliciting caregivers’ goals, we began with a broad approach and modified it as we learned more about the project and the team received more training. Initially, the family care coordinators (FCCs) were encouraged to have our usual intake conversations with caregivers with the addition of a parent experience question to be asked at the conclusion of the call: “Do you feel I understood your goals and priorities during this conversation?”
This project’s terminology was used, rather than the already implemented ‘needs met’ question from the HMG National Center. Then, the coordinators began using the word ‘goal’ with caregivers and framing the conversation with caregivers’ wants in mind, rather than needs/concerns. The FCCs either asked if they had a goal and waited for the caregiver’s response or the FCCs would state a goal that was ascertained from listening to them describe a concern or need. The goals were documented in the care coordination log and noted if the parent or FCC identified the goal. If the goal was identified by the FCC, the caregiver confirmed /agreed with the stated goal, or they declined the goal. The identified goal was also used during follow-up care coordination where the FCC restated the goal, especially if the caregiver had not followed through with any of the referrals or next steps.
The incorporation of MI was rolled out with the continued support from UBMIC, and was a harmonious transition as the FCCs realized that many of the MI strategies were already a part of their conversation with caregivers. When we learned that it is challenging to measure ‘what is an MI call?’, as any incorporation of any of the MI strategies qualified, we did not add MI metrics to STAR as we embraced the fact that all our calls were ‘MI calls.’ Group and individual coaching sessions, inclusive of recorded calls for MI coding and implementation of reflection forms, were instrumental in integrating this enhancement into our CAP.
National Center: What were some of the benefits of integrating the enhancement?
HMG Orange County: We continued to monitor parent follow-through with the resources and referrals provided to families throughout the project. We predicted and found that there was a decrease in the number of documented barriers associated with instances of ‘parent not following through’ when using the enhanced MI strategies. The FCCs learned about barriers during initial intake conversations and follow-up care coordination.
Our timeframe for the baseline was March through July 2022. For comparison, we tracked this same data from March through July 2023 and found that caregivers were more likely to follow through when MI, goal identification, and review were used during all the conversations.
- March – July 2022 = 30 barriers documented where parent did not follow through
- March – July 2023 = 8 barriers documented where parent did not follow through
During the GCC project, the HMG Orange County team embraced learning and practicing MI strategies during conversations with families. Five team members participated in the trainings and attended local weekly meetings to discuss using MI. Various MI techniques were discussed and identified for practice each week and then experiences were shared with the group the following week. The HMG Orange County team was highly engaged and reported anecdotally that they felt their conversations with families had changed due to MI because it allowed for better rapport and more in-depth conversations. We also monitored call length and noted that incorporating MI strategies did not increase time spent on the phones. Coordinators reported that parents were more open during conversations that were parent-driven and when using MI-style conversations.
National Center: What challenges have you and the team navigated integrating the enhancement into the HMG Model?
HMG Orange County: Initially, an ongoing challenge when implementing these new activities/projects was the intensive MI training (coaching, meetings, recordings, etc.) impacted our CAP staffing. However, the staffing issue related to this project was resolved when the intensive training phase concluded. We experienced staff turnover during the project; however, the new FCC, with the support of UBMIC, received streamlined coaching and quickly caught up and transitioned into the ongoing training with the rest of the team.
Eliciting and documenting ‘goals’ with caregivers was a challenge at times. It became apparent that not all CAP contacts with parents warranted goal identification. Some conversations were more transactional in nature and didn’t fit with goal identification. Our team came to better understand how to elicit a specific goal from a caregiver with the use of MI strategies and to consider when this approach was useful. This minimized the need for the FCCs to press the caregiver to identify a goal or for FCCs to do so in hindsight. We also overcame the challenge of understanding how eliciting goals using MI would be identified, documented, and reported with the use of PDSA cycles and metrics in STAR as mentioned in question one.
National Center: What approaches/strategies have been sustained to date?
HMG Orange County: Based on our findings and FCC feedback about eliciting and documenting goals, our team agreed to continue documentation of goals at the FCCs discretion. Caregivers’ goals are documented in short-response boxes in the STAR care coordination log that do not have pre-populated lists of goals. These care coordination logs are completed during intake, referrals, and follow-up care coordination.
Since the conclusion of the project, our team has expanded to include a CAP supervisor who is reviewing and coding cases to support this work, as well as leading a monthly meeting on care coordination strategies. The CAP supervisor has been trained in MI with the support of UBMIC to ensure we continue to implement MI and goal identification.
We have also continued with internal bi-weekly MI/GCC meetings, one with the entire HMG team (GCC Corner at our monthly team meeting) alternating with a second meeting on care coordination strategies that includes those trained in MI. We have used approaches such as role play, self-reflection tools, and group discussions to empower FCCs to self-identify strengths and areas of opportunity as we continue incorporating MI into each call. These monthly huddles include learnings from the book recommended by UBMIC, titled Motivational Interviewing, 4th Edition, Helping People Change and Grow.
We feel strongly that MI is an extremely valuable enhancement to HMG systems when implemented at the CAP.
Conclusion
Overall, HMG Orange County demonstrated the successful integration of MI strategies within the HMG CAP. By prioritizing parent goals and incorporating MI techniques, the team observed a significant decrease in documented barriers related to parent non-follow-through with referrals. The integration of MI fostered stronger rapport with families and facilitated more in-depth conversations, all while maintaining efficient call times. While initial challenges related to staffing and goal identification were addressed through ongoing training and refinement of the process, the team successfully sustained key elements of the intervention, including regular MI training sessions and ongoing peer support.
These findings highlight the potential for MI to enhance the effectiveness of CAP services across the entire HMG National Affiliate Network, allowing HMG systems across the country to take a more family-centered, goal-oriented approach to early childhood support.
Read the Executive Summary
Read the Full Goal Concordant Care Final Report
(Available to HMG affiliates only – contact your state/system lead for login access)
Learn More about the Goal Concordant Care Learning Community
Gabby Hamel is the Communications & Network Relations Specialist for the Help Me Grow National Center at the Office for Community Child Health at CT Children’s Medical Center.