WrapCT Presents: PLANNING AND MANAGING TRANSITIONS

Learning CollaborativeWrapCT.org

Mary Jo Meyers-2011 consultmjm@hotmail.com

WrapCT PRESENTS:

PLANNING AND MANAGING TRANSITIONS

TRANSITION PLANNING BEST PRACTICES:• Begins on day one• Utilizes the family’s expertise in problem solving• Is discussed and planned for at each plan of care

meeting• Requires exceptional crisis/safety planning• Utilizes the Wraparound process in a planful and

concise manner

TRANSITION PLANNING BEST PRACTICES CONT’• Instills hope for a better future• Utilizes a well balanced team consisting

mostly of natural/informal supports• Community resources and available supports

are explored well before ending• Success is celebrated soon and often• Empowers the Youth and Family to mobilize

their own team as needed

NECESSARY SKILLS FOR FACILITATORS• The ability to communicate and behave with

confidence and reassurance• Good planning and organizational skills• Encouragement and support are provided to the

family in a genuine manner• The ability to be introspective about who’s needs

are being met and who’s really having abandonment issues

• The ability to be understood and plan around underlying needs

• Outcome oriented

FAMILIES DESERVE TO KNOW THEY ARE TRANSITIONING

TO SOMETHING RATHER THAN AWAY FROM SOMETHING

TIPS FOR TRANSITION PLANNING• Negotiate transition with the full team• Allow Family voice to be heard about

transition• Plan for interventions to fade over time• Set clear transition benchmarks• Use life domains as a guide for system

TIPS FOR TRANSITION PLANNING• Keep track of incremental progress – no

matter how small the increments• Let the family acquire its own sense of

agency and urgency• There will be set backs – look for the

learning opportunity• Celebrate transitions the family’s way

THE FOUR PHASES OF THE WRAPAROUND PROCESS – TRANSITION FOCUSED1. Engagement – Learning about the family’s

support system2. Planning – Bringing existing supports in and

deciding how to build new supports3. Implementation – Building bridges to the

community, enhancing or enlarging competency, creating opportunities for a better life

4. Transition – Help is in place. Team is mobilized to act when needed.

TEAMS & TRANSITION• Assumptions & Values

• People working together can generate more solutions• People working together can generate more creative

solutions• People/Families who are hurting deserve all of the

people in their lives to be on the same page• The best teams combine the expertise of the system

with the compassion of the family’s people• In order to have full participation of informal/natural

supports, system people will need to accommodate & invite

• Wraparound teams should be learning & doing groups

• Healing comes from acting together

CONNECTIONS AND SUPPORT MAP

Friends Family

Community Work/School

FIRST PHASE OF WRAPAROUND:TEAM DEVELOPMENT• Meet with family & stakeholders• Get the story• Gather perspectives on strengths & needs• Assess for safety & rest• Provide or arranges stabilization response if safety

is compromised• Explain the Wraparound process• Identify, invites & orients Child & Family Team

members• Complete strengths summaries & inventories• Arrange initial Wraparound team planning meeting

SECOND PHASE: PLAN DEVELOPMENT• Hold an initial (or 2) Child & Family Team Plan Development

Meeting• Introduce process & team members• Present strengths & distribute strength summary• Solicit additional strength information from gathered group• Lead team in creating a mission/vision• Introduce needs statements & solicits additional

perspectives on needs from team• Create a way for team to prioritize those needs that will

accomplish mission/vision• Lead the team in generating brainstormed methods to

meet needs• Solicit or assigns volunteers• Document & distribute the plan to team members

RESPONSIVE CRISIS PLANS:• Tells team members how to react

immediately and responsively to the events at hand

• Are practical and realistic• Builds on functional strengths of the team

and community• Include as many natural and informal

supports as possible• Keeps everybody involved safe

PROACTIVE SAFETY PLANS:• Aim is to prevent crisis• Focuses on what to do instead of what not to

do• Is based on needs identified in the plan of

care• Works towards uncovering underlying needs

EFFECTIVE CRISIS/SAFETY PLANS:• Describe specifically the unsafe behavior• Analyze function (unmet need) of the unsafe

behaviors• Take the physical aspects of the setting into

account• Describe specifically safe alternative

behaviors• New strategies reflect functional strengths,

culture and choices of those involved• Steps are specific and written in order of use,

least restrictive to most

HELPFUL HINTS:• Keep the plan focused• Include rules of household, school or

community• Discuss rewards and consequences for

safe vs. unsafe behavior• Consult with people who specialize in

needed area of concern• Watch and plan for regression during

stressful times

FAMILY VISION: A DEFINITION• Definition: The family’s vision represents

their goals, hopes & dreams for their own family

• What are the benefits of identifying a family vision?• It helps families recognize the legitimacy of

their own perspective & voice• It creates meaning & purpose for families • It helps professionals validate the right to

the family to have their own perspective• It helps professionals understand the

family’s sense of themselves beyond services & systems.

REMEMBER• Systems have no obligation to

accomplish a family vision. • Systems create joint goal or

mission statements with families but families have a right to “own” their vision even if professionals disagree.

STRENGTHS DISCOVERY• Look for functional. A list of

attributes does not allow you to plan

• Are the key to any transition• Lead to sustainable plans

NEEDS• Check first to see if the needs

identified when met will lead to the family’s vision

• Uncovering underlying needs leads to a more precise fit of strategies

• Families deserve to have their real concerns addressed

STRATEGIES

• Look to functional strengths first• Should be written in a

manner in which all team members know what their job is• Should be reviewed for

progress at least monthly

THIRD PHASE: MANAGING ONGOING PLAN OF CARE MEETINGS1. Accomplishments – Check with family first2. Assess progress – Check for needs met not

just services delivered3. Adjust the plan – Remember you are planning

for transition4. Assign new tasks – Use the team!

ESTABLISH YOUR ANCHORS• Anchors may be• Goals• Results• Outcomes

• Define what life would like if the identified need were met

• Allows you and the team to define the destination

TIPS FOR ESTABLISHING YOUR ANCHORS• Create a view

• Future view of a household• “Normalized” view of a typical situation

• Create easy “counts”• Avoid anything that makes too much work• Percentages work/impression counts

• Identify the frequency of summary• Weekly, monthly, at least quarterly

• Ask the team to review the “facts”• Summarize the details• Graphs or Charts

• Bring a summary to the meeting

TIPS FOR CREATING YOUR ANCHORS• Avoid the control and compliance view• Rather than he must go to school it should

be he will attend school because … • Keep teams from going off track

• Avoid over complicating• Limit your indicators to no more than five• Impressions count, ask the family to give

you a report• Use your outcomes to guide the team• Bring your summary, discuss it rather than

falling into the detail trap

FOURTH PHASE OF WRAPAROUND:PLAN COMPLETION & TRANSITION• Hold meetings

• Solicit all team members sense of progress• Chart sense of met need• Has team discuss what life would be like after

Wraparound• Review underlying context/conditions that brought

family to the system in the first place to determine if situation has changed

• Discuss the what if?• Facilitate approach of “post-system” Wraparound

resource people• Formalize structured follow-up if needed• Record accomplishments; what worked, didn’t work• Create a commencement ritual appropriate to family &

FOURTH PHASE OF WRAPAROUND:PLAN COMPLETION & TRANSITION• Completed Products

• Written Transition Plan that details how to access ongoing services/supports if necessary

• Written crisis plan that details who & how to contact individuals

• Follow up phone numbers for team members• Formal Discharge Plan detailing strengths &

interventions that were successful & those that weren’t

• Written letters of introduction for anticipated next formal service access

ELEMENTS OF GOOD TRANSITION WHEN COMPLETING THE FORMAL WRAPAROUND PROCESS• Families have some sense of what comes

next• Families have increased confidence in their

own abilities to make their own vision real• Families have a sense of connection to

various team and community members• Families know what to do if things go wrong• Families are able to chart & recognize their

sense of progress since the beginning of formal Wraparound

TRANSITION PORTFOLIO• Transition portfolio contains the plan including a

crisis/safety plan and all supporting documentation

• It has multiple purposes:• Help the family see what they have

accomplished• Remind the family of effective recovery

strategies they can use• Help other agencies down the line know what

worked, what didn’t and who to call• Help the family know who to call

EFFECTIVE TRANSITION PLANS• Begin early in the Wraparound Process• Build on what has been accomplished• Shift the balance of activity from the system to

the community• Assure needs and outcomes have been met• Answers the questions of what will it take for the

child to do well at home, in school and in the community

• Support rather than abandon the family

FOUR BAD REASONS FORTRANSITIONING OUT OF WRAPAROUND• Team is out of money• Team is out of ideas• Team is out of hope• Team is out of patience

TRANSITION:

CHALLENGES AND SOLUTIONS ACTIVITY

WrapCTLEARNING COLLABORATIVE

Our vision as a statewide learning collaborative is that all children, youth, and families are able and capable of achieving optimal levels of

functioning at home, in the community, at school and/or work.

WrapCT Steering Team• Jan Bendall, Rushford; Ray Bieber, Child & Family Guidance; Tim

Bowles, SEMHSOC; Jill Coffin , U CF S; Dorothy Contrastano, FAVOR; Tim Cunningham, Wellpath; Paloma Dee, NAMI, CT; Nicole DeRobertis, MFCGC; Hal Gibber, FAVOR; Victor Gonzalez, Wheeler Clinic-Hrtfd; Gabrielle Hall, Clifford Beers; Mary Held, Waterbury FFP; Katy Keegan, West Haven – Bridges; Virginia Lopez, Child & Family Guidance; Tim Marshall, DCF; Tabor Napiello, Wheeler Clinic-Plainville; Kristen Penta, Bridgeport Schools; Mark Plourd, Wheeler Clinic-Hrtfd, Cheryl Tedesco, Child & Family Guidance; Paige Trevethan, Bridges; National Consultants: Verneesha Banks, Wraparound Milwaukee; Mark Horwitz, Westfield State Univ.; Mary Jo Meyers, Wraparound Milwaukee

Contact information for WrapCT: Tim Marshall 860-550-6531; tim.marshall@ct.gov

Contact for training material: Mary Jo Meyers 414-251-7521; consultmjm@hotmail.com

WrapCT Presents: PLANNING AND MANAGING TRANSITIONS

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