Transcript Service Coordination Powerpoint for community groups

Service
Coordination
Tuscarawas County Family and
Children First Council
Family and Children First Councils
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BRIEF overview
– Established in statue in 1993 (ORC 121.37)
– Local Council in each of the 88 counties with
the charge of:
Tuscarawas County Family and
Children First Council Structure
Governing Board
Administrative
Agent
Service
Coordinator
Service
Coordination
Committee
Council
Manager
Budget
Committee
Advisory Committee
Council
Function
i.e. HMG
Council
Function
i.e. OCTF
Council
Function
i.e. ACAP
Coordinating Systems and Services
=
Service Coordination
Coordinating Systems and Services
=
Service Coordination
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Service Coordination Guidance Document
– Identifies “have to”s of SC process including:
 Diversion of children from Juvenile Court
 Meeting before out-of-home placements
 Monitoring children in out-of-home placements
Service coordination is for any
child age 0-21 with “multisystemic needs”
Local Service Coordination Flowchart
Referral and Release of information to
Service Coordinator
SC contacts the family, sets up
appt. for assessment and
discusses SC tracks
Track 1- Family
Stability Model
Track 2- Family Team
Model –aka Wraparound
Assessment completed with
family. Safety Plan Created.
Service Coordinator and family create
service coordination plan. Written/verbal
communication with providers
Meeting with family, supports, providers
etc. Assessment reviewed and needs
prioritized. Plan developed to address
immediate needs that threaten stability.
AT LEAST monthly
communication regarding
stability and plan review.
Ongoing meetings at prescribed times with team
and supports present to review and update plan.
Case Closure.
(is stability
maintained? Or is
family still engaged?,
etc.)
Local Service Coordination Process
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Referrals
– Come from anyone (parent, provider, school,
etc.)
– Shortened process (1 ½ pages / checkboxes)
– Release of information needed
– Referral source will briefly describe the SC
process to the family
– Referral sent to the Service Coordinator who
will contact the family within 3 business days
Local Service Coordination Process
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Assessments
– Service Coordinator meets with family to
discuss strengths, needs, and cultural issues
within 5 business days in an agreed upon
location
– Reviews the service coordination process in
more detail
– Releases of Information get signed
– Family and Service Coordinator work together
to identify appropriate TRACK
Local Service
Coordination Process
Track 1 – Family Stability Model
Local Service Coordination Process
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Track 1 – Family Stability Model
 For families with less intensive needs/less
risk
 SC plan created with written/verbal
feedback from providers
 Family and service coordinator responsible
for plan
 AT LEAST monthly contact until case
closure
Local Service
Coordination Process
Track 2 – Family Team Model AKA
WRAPAROUND
Local Service Coordination Process
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High-Fidelity Wraparound
The wraparound process is a way to improve the lives of
children with complex needs and their families. It is
not a program or a type of service, but a team
based planning process used to develop plans of care
that are individualized based on the strengths and
culture of the children and their family.
The plan is needs-driven rather than service-driven,
although a plan may incorporate existing categorical
services, if appropriate to meet the needs of the
consumer. The initial plan should be a combination of
existing or modified services, newly created services,
informal supports, and community resources, and should
include a plan for a step-down of formal services
Why Wraparound?
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Intervening effectively with these young
people has proven very difficult and
outcomes have been poor. Why?
 Children and family needs are complex
 Family and youth are rarely fully engaged in
services
 Systems work in “silos”
What’s different in Wraparound?
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Plans are designed by a team of people most important
to the caregiver, youth, and other family members
Plan is driven by and “owned” by the family, youth, and
other family members
Strategies in the plan include supports and interventions
across multiple life domains and settings (i.e., behavior
support plans, school interventions, basic living supports,
help from friends & relatives)
Natural supports and unique strengths are emphasized
in team and plan development
Plans include supports for adults, siblings, and family as
well as the “identified youth”
Local Service Coordination Process
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Track 2 – Family Team Model
– Those individuals who have personal or
professional relationship with the family
 Formal and informal supports
– Review of assessment summary
– Safety/crisis plan
– SC Plan created around PRIMARY need(s) and
divides responsibilities among group
Local Service Coordination Process
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Service Coordination Plan
– Family identifies their long term vision
– Family and team work together to identify and plan
around immediate needs
– Family and team clearly identify barriers and plan
around them
– Family and team incorporate strengths to help meet
goals
– Formal and informal supports incorporated
– Progress is reviewed. Plan is updated as needed.
Goal of Service Coordination
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Address issues that are impacting family stability
Maintain the child in the home when safely able
to do so
Strengthen and empower the child and family
unit
Connect with community resources and supports
Ensure that the formal and informal supports are
working as a part of a team to help the family
The Jones Family – Case Example
Mom and Dad, Tommy and Ben
 Tommy is 12 and was adopted by the
family as a toddler. He is struggling in
school and they are considering unruly
charges, he refuses to go to counseling,
and has been physical with 7 year old
Ben. The case is referred by the school
social worker.
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Case Example
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Family agrees to Family Team Model due to the level of
crisis, risk of court involvement, potential placement in
Attention Center, etc.
Assessment is completed.
Strengths – Enjoy camping together, Tommy and dad
are artistic, marriage is strong
Informal supports – church family, sister-in-law, YMCA
coach
Needs- Failing multiple classes at school, conflict with
principal; transportation (dad’s job is at risk); finances
are tight – increases parent stress; manage anger to
increase success at school and decrease conflict at home
Case Example
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Family Team Model
– Mom, dad, Tommy, school social worker, teacher,
juvenile court representative, church member, sisterin-law, YMCA coach come together for a meeting
– Review assessment (strengths, needs, cultural issues)
– Create safety plan
– Identify needs and prioritize
– Identify and plan around barriers
– THIS PROCESS IS FACILITATED BY SERVICE
COORDINATOR
Case Example
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Two primary needs as determined by
family=
– School (failing, trouble with principal, mom
called to school constantly, creates conflict
with the family, hanging out with the “wrong
crowd”)
– Finances (car died, bills going unpaid, dad’s at
risk of losing job)
Case Example
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School –
– School personnel indicates Tommy is having
most difficulty in math and science and acts
out the most during and after these two
classes
– Mom agrees that homework/grades/school
functioning is typically what starts conflicts at
home
Case Example
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Service Coordination Plan - School
– YMCA coach has a teammate who is studying math/science in
college who may tutor Tommy
– Church member volunteers to watch Ben so Tommy can be
tutored at home with little distractions
– School social worker agrees to create behavioral reward system
to improve Tommy’s behavior and decrease Tommy’s negative
interactions with principal
– YMCA coach willing to have Tommy be statistician for H.S.
soccer team to increase time with positive male role
models/decrease time with the “wrong crowd”
– Family and TCFCFC will share the cost of enrolling Tommy in an
art class; Church member will provide transportation
Case Example
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Service Coordination Plan- Finances
– Parents agree to debt management/budgeting
classes
– Parents agree to Ways to Work to help dad
purchase a vehicle
– Sister-in-law agrees to work out
transportation plan so dad can get to work
– Parents agree to contact JFS regarding
applying for PASS funding for families of
adopted children
Case Example
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How does this impact the local system?
– There is a financial and emotional cost if
Tommy receives charges in Juvenile Court
– The risk of Tommy being placed in a
specialized school decreases
– There is a financial and emotional cost if
Tommy’s is placed outside of the home
 Cost to the school
 Cost to the systems
 Cost to Tommy and family
Case Example
 The process has supported Dad remaining a
member of the workforce
 The process has involved informal supports to help
the family meet some of their needs vs. creating a
plan that relies on systems
Case Example
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In between first and second family team
meeting –
– Service Coordinator
 facilitates enrollment of Tommy in art class
 Contacts school to obtain behavioral plan and
shares with the family’s team
 Confirms appointment time for Ways to Work and
Budgeting meeting
 Verifies progress has been made on tutoring plan
Case Example
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Second Family Team Meeting within 10 business
days
– Review family plan
 Meeting occurred for Ways to Work and Budgeting
 School created behavior plan last week – can’t report on
progress
 Art class starts next week
 Coach unable to find tutor for Tommy but he is helping at
the YMCA
 Family found to be eligible for PASS funding
 Dad able to get to work through sister-in-law and co-workers
Case Example
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In between second and third meetings
– Service Coordinator
 Verifies Tommy is attending art class
 Determines progress with Ways to Work/Budgeting
meeting
 Works with school to determine progress with
behavior plan and potential student tutor
 Determines progress in involvement with
Coach/YMCA
Case Example
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Third Family Team Meeting
– Family and team discuss where progress has
been made and areas of continued concern
– Mom is questioning potential FAS due to
recent information regarding Tommy’s
biological family
– Service Coordinator updates Family Plan to
include any additional issues, such as
connection with Health Dept. to learn about
FAS
Case Example
As the level of risk and family crisis decreases,
Family Team Meetings occur less and less
frequently.
Frequency may increase if an additional crisis
occurs.
Service Coordination ends when family can
navigate the system, is not experiencing crisis,
risk of removal is decreased, and supports are
maintained or no longer needed.
Questions?
Contact info:
 Tuscarawas County Family and Children
First Council - 330-343-2286
Rindy Brace, Service Coordinator
[email protected]
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