A new paradigm for parent and patient education

Abstract

Details of an innovative model for providing health education to families and patients using a coordinated series of skill-based educational opportunities are described. The model offers a variety of educational courses for parents of children at each developmental stage. Each course provides transferable skills that assist parents in caring for their children and/or managing their children’s psychosocial problems. The development and evaluation of these educational opportunities, and the application of this program to patient education in paediatric settings are also discussed.

The Chedoke Child and Family Centre is a division of the Children’s Hospital at the Hamilton Health Sciences Corporation, Hamilton, Ontario. The centre provides children’s mental health services, children’s rehabilitation services and developmental paediatric services to patients who are mainly from the surrounding community (1). The centre is somewhat unique in that it provides all of the above services, as well as several other specialized children’s services, under one organizational structure.

In the fall of 1997, the centre underwent a major redesign of the way that services are delivered to children and families in the community (2,3). A central feature of the redesign was the development of a wide-ranging Community Education Service (CES), which provides lectures, workshops, and courses to children and families. The present paper discusses the challenges that led to this new model of service delivery, the development of educational opportunities and the ongoing evaluation of services provided. The implications of using this model to deliver more effective and cost efficient education to paediatric patients and their families are also discussed.

CENTRE REDESIGN

The redesign of the centre’s services came about because of two related factors. The first factor was the fiscal pressure that the organization experienced in the mid-1990s. The centre is funded by several provincial ministries, including the Ministries of Health, and Community and Social Services, and it also attracts independently funded research initiatives. Fiscal pressures included major budgetary cuts to the parent hospital organization, a decade of little or no new funding for children’s mental health services and decreasing funding for research initiatives.

The second factor was a growing sense on the part of staff that patients referred to the centre were waiting longer for services and becoming more troubled as they waited. It was clear that many children with identifiable mental health problems in the community were not receiving help for those problems (4), and, when children wait a considerable time for treatment, problems are often exacerbated.

The centre’s redesign team struggled with the above issues, and a re-examination of how services are delivered led to the paradigm shift. Patients are referred to the centre through physicians, schools, social service agencies, parents and others in the community. Considerable information is gathered about each child, his or her development (both physical and psychosocial), and the history and severity of the child’s problem. The order in which patients are seen is based on triage, and the information gathered about each child is used to determine the order. Next, patients are assigned to a clinician, and an assessment is completed. If a significant problem is found, the child is assigned to a clinician for treatment; usually, the same clinician that assessed the child is assigned.

In reviewing past charts and in discussions with clinicians, the redesign team noted that, often, the first step in providing treatment was to provide information and education about the problem or disorder. This was usually done on a one-to-one basis in the clinician’s office. The clinician would generally present information verbally, although written materials were supplied in a few instances. Audiovisual aids or multimedia tools were seldom used, and few clinicians were trained in the basic principles of adult education.

Both patients and clinicians were dissatisfied with this model of patient education, and much of the effort and energy of the centre’s staff was spent on battling increasing waiting lists. The centre began to change this model of service delivery by offering several large lectures on some of the most common problems experienced by patients and their families. The lectures were offered initially on a ‘one time only’ basis, but repeated requests led to some lectures being offered on a regular schedule.

At the same time, a large group intervention model for parents of children with behavioural difficulties was being developed and evaluated by the Community Parent Education (COPE) Program. The COPE program was designed specifically for parents of children aged three to 12 years with behavioural problems, and was shown to be more effective and efficient in assisting parents with their children’s behaviour than the traditional ‘one-on-one’ family counselling offered in outpatient clinics (5). As well, the parent training intervention offered by the COPE Program was shown to be more likely to engage families with a lower socioeconomic status (5).

These circumstances led to the idea of developing a curriculum of workshops, courses and groups to cover a number of the most common problems that bring families and children to the centre. These educational offerings are divided into several categories according to the developmental stage of the child or the specific problem (eg, training courses for parents of infants, preschoolers and elementary aged children, and for parents of preteens and teenagers). Many of the courses are designed to build on skills that were taught in earlier sessions.

All educational events offered through the CES must be available at no cost to any parent or child in the community. Participants are not necessarily ‘patients’ or ‘clients’ of the service, and advance registration is not required for most single-session courses. Most events are held at community settings such as schools, day care centres, libraries or recreation centres. Research has shown that community locations are more convenient venues for most parents (5).

Educational events are marketed through several channels. A 12-page flyer of current course offerings is circulated three times a year. The flyer is sent to all physicians, schools, day care centres, social service agencies and libraries in the catchment area. Copies of the flyer are mailed directly to patients referred to the centre. Community members may request a copy of the flyer through an automated phonemail service. Courses are also listed on the centre’s web site, and the centre takes advantage of free ‘community information’ space in local newspapers.

RESPONSE TO EDUCATIONAL EVENTS

In the past year, the centre has offered more than 275 educational events with more than 5000 participants. A philosophical shift away from mainly ‘serving individuals with problems’ to providing ‘services to populations of people with similar problems’ underlies the centre’s change in service delivery models. This population-based approach is possible partly because many of the centre’s services are not funded on a ‘fee-for-service’ approach but rather on a global funding basis. Services that are funded on a fee-for-service basis (mainly professional consultations from physicians and other regulated health professionals) have contributed some educational opportunities, but the further participation of those professionals will depend on an equitable remuneration method for the time and expertise of the health professionals involved.

Courses offered by the centre are evaluated. The CES developed a standardized evaluation questionnaire that is provided to all programs at the Chedoke Child and Family Centre or the CES works with group leaders to customize an evaluation. Data entry for the evaluation is performed centrally, and the goal is to provide group leaders with the results of an evaluation within two weeks. The use of standard questions and repeated measures allows comparisons between each occurrence of the same educational event, as well as between different events. A longer term goal is to link the information from the CES to the Child and Family Centre’s overall service delivery information system. This will allow the effect of the new model on later service delivery to be examined. Eventually, it will allow comparisons of outcomes for patients and families who are involved in the education programs with those who do not participate.

To monitor the impact of these educational programs offered by the Chedoke Child and Family Centre, at the last session participants complete the questionnaire mentioned earlier. An analysis of questionnaires from 738 participants was completed recently. The sample included only those clients who attended a course offered directly by the centre; some selected courses used their own client satisfaction questionnaire. The standardized questionnaire uses a five-point Lickert-type scale to measure client agreement with 14 statements that focus on session amenities, course processes and the impact of the course on participants.

Not surprisingly, in response to questions on session amenities, clients who attended the sessions agreed that “the location of this workshop was convenient” (77.6%), “the time of this workshop was convenient” (90.6%) and “this was a comfortable setting to meet in” (89%). Because only participants were surveyed, individuals who found the time or location of the sessions to be inconvenient are under-represented. Further analysis of accumulated data may help identify optimal locations and times for various courses. An anecdotal finding is that morning courses seem to be most convenient for single parents, while evening courses are more convenient for couples.

Course process questions, based on key success factors identified in earlier research on parent training programs (6), examined course participation and characteristics of the group leader. Participants agreed that “talking with other participants was helpful” (90.3%), “the leader was knowledgeable about the topic” (97.9%), “the leader encouraged discussion” (97.4%), and “the leader was concerned about the participants” (96.3%).

The last set of questions focused on the participants. Participants agreed that “I learned something new” (92.6%), “I plan to use what I learned” (94.8%), and that “this workshop will be helpful to me” (95.1%). While these results are all very positive, it will require further longitudinal surveys to determine the actual impact that the educational sessions may have on health outcomes.

OTHER IMPACTS OF REDESIGN

In addition to changing professional practice patterns, the CES has also had an impact on the nature of information delivered at educational sessions. When individual services or clinics were responsible for educating only ‘their’ patients, educational offerings were often geared to a very narrow population. For example, a relaxation group for teens with gastrointestinal problems would be offered in one area, while a relaxation group for children with anxiety problems was offered somewhere else. Although the skills taught in each program were nearly identical, by narrowing the recruitment process to a particular clinical problem, the overall use of these programs was reduced. If patients with gastrointestinal problems were unable to attend a session at the scheduled time and place, they would often have to wait a considerable length of time for the next course. With more sessions offered at more varied times and in more locations, patients are more likely to use these services. As well, the educational offerings are focused on the skills that a family or child needs to manage a problem rather than on a specific disease or problem.

Often, an additional effect of offering educational programs as a first level of intervention is a change in the role played by the health care professional involved in those programs. Instead of being an ‘expert’ who gathers information from the patient and pronounces a course of action, the health care professional becomes an educator who shares knowledge and expertise in a large group and who acts as a resource to that group. Participants, if the session is facilitated well, feel able to make knowledgeable decisions about their health. The CES is confident that this will lead to improved compliance and better outcomes.