Towards Implementation of an Early Intervention Model by a Paraguayan Organization

Recebido em: 16 set. 2019. Aprovado em: 14 dez. 2019. Publicado em: 25 mai. 2020. Abstract: Implementation science has been developed to help understand why evidence-based practices are not adopted as rapidly as they might. We describe here the process a rehabilitation center in Paraguay is undergoing to transform itself into a state-of-the-art early intervention program. We describe the organization and its contextual strengths and barriers, the model it chose to implement, and the implementation procedures it has attempted. The implications for model fidelity are highlighted, as this organization needed to make adaptations to the model as designed, to fit the particular context of its mission and the Paraguayan culture. Features of the Routines-Based Model are described.


"To improve is to change; to be perfect is to change often." Winston Churchill
Four years ago, 2-year-old Joaquín's mother carried him for the long walk to the bus stop, on the bus, and from the bus to Teletón. Teletón is a rehabilitation center in Asunción, the capital of Paraguay. At the center, Joaquín and his mother waited until their appointment time, when a physical therapist greeted them and took Joaquín to the therapy room. There, she manipulated his joints, working on contraction and extension, and she again held him in standing to see if he could take his first step with her assistance. After 40 minutes, if he lasted that long before crying, the therapist returned him to his mother. The therapist sometimes had a suggestion for her to try at home. Joaquín's mother checked with the receptionist about the appointment for the following week and she began the long trek home.
Today, Joaquín and his mother still come to Teletón. He now walks with arm crutches, with a slow and awkward gait. At therapy time, both he and his mother go to the therapy room with the physical therapist, who makes sure he has access to toys and books. Most of the session involves Joaquín's mother and the therapist talking. They discuss the mother's success with the interventions she said, at the previous session, she wanted to try through the week.

An Organization With High Ideals
The Teletón context is important for understanding the strengths and challenges involved in making this change. We describe here what they thought needed to change and how they arrived at those conclusions.

Structure
Teletón is organized in four rehabilitation centers distributed in four locations in Paraguay: Asunción, Coronel Oviedo, Paraguarí, and Alto Paraná. These locations make it more possible for families from around the country, including rural areas to have access to services. In these centers, beyond rehabilitation, Teletón attends to family needs from a comprehensive and holistic perspective. As we will see, the philosophy of the current leaders was family centered even before implementation of the model. The difference now is that they have a path to follow.  In 2014, two of the three service directors at Teletón enrolled in the first cohort for the master's degree program at UCV. The staff say these two pioneers "got hooked on family-centered practices. " When they returned to Paraguay, they found that their third colleague resisted the information. This meant that professionals worked in teams, as opposed to working in isolation, and they communicated with each other. This helped make the RBM, which focuses on the primary-serviceprovider teaming approach, feasible. As one leader said, "We were ready for change, and we were looking for this important role of families."

Routines-Based Model
The

Needs Assessment of Children and Families
To

Intervention Planning
The RBI produces 10-12 child and family goals.
Family goals can be related to the child and his or her disability or can be for the parents' wellbeing. This intervention planning is different from having only two or three goals or having only child skills for goals.

Service Delivery Methods
The RBM employs a primary-service-provider (PSP) approach, in which one person is allied with the family, partnering with them at every visit 10, 20 .
This PSP is supported by other team members from other disciplines who provide consultation through informal means, meetings, or joint visits with the family. This service delivery method is different from having different professionals working separately with the family.

Performance-Checklist-Based Training
A checklist exists for every practice in the RBM.
Checklists serve three purposes: They define the practice, they provide a platform for feedback, and they provide implementation fidelity data 1 .

Formative Evaluation
To determine how well the model is being

Conclusion
The story of Teletón's implementation journey is a case study in the reciprocal effects of ideas and action, as shown in Figure 1. Research, Theory, Experience  Paraguay has a high rate of domestic violence, especially in poor families, even compared to other Latin American countries 8 . When the professionals started hearing the horror stories of many families, they were emotionally affected.
They probably also, in the backs of their minds, were aware these stories were not new; they just had not been heard before. The second challenge related to cultural sensitivity is that the culture at Teletón is to look after the staff, especially the staff's feelings. Leaders ensured staff knew they could talk about their feelings of sadness, empathy, and compassion fatigue. From an implementation standpoint, they will have to guard against allowing staff to stop listening to families. Without a structure to monitor the fidelity of the RBI or the routines-based visits, it will be difficult to ensure staff are still listening to families.