Service Coordination

Service Service CoordinationCoordination

Tuscarawas County Family Tuscarawas County Family and Children First Counciland Children First Council

Family and Children First Family and Children First CouncilsCouncils

BRIEF overviewBRIEF overview– Established in statue in 1993 (ORC Established in statue in 1993 (ORC

121.37)121.37)– Local Council in each of the 88 counties Local Council in each of the 88 counties

with the charge of:with the charge of:

Tuscarawas County Family and Tuscarawas County Family and Children First Council StructureChildren First Council Structure

Governing Board

AdministrativeAgent

Service Coordination Committee Advisory Committee

ServiceCoordinator

BudgetCommittee

Council Functioni.e. HMG

Council Functioni.e. OCTF

CouncilManager

Council Functioni.e. ACAP

Coordinating Systems and Coordinating Systems and Services Services

==Service CoordinationService Coordination

Coordinating Systems and Coordinating Systems and Services =Services =

Service CoordinationService Coordination Service Coordination Guidance DocumentService Coordination Guidance Document

– Identifies “have to”s of SC process including:Identifies “have to”s of SC process including: Diversion of children from Juvenile CourtDiversion of children from Juvenile Court Meeting before out-of-home placementsMeeting before out-of-home placements Monitoring children in out-of-home placementsMonitoring children in out-of-home placementsService coordination is for any Service coordination is for any child age 0-21 with “multi-child age 0-21 with “multi-systemic needs”systemic needs”

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.

Case Closure.(is stability

maintained? Or is family still engaged?,

etc.)

Ongoing meetings at prescribed times with team and supports present to review and update plan.

Local Service Coordination Flowchart

Local Service Coordination Local Service Coordination ProcessProcess

ReferralsReferrals– Come from anyone (parent, provider, school, Come from anyone (parent, provider, school,

etc.)etc.)– Shortened process (1 ½ pages / checkboxes)Shortened process (1 ½ pages / checkboxes)– Release of information neededRelease of information needed– Referral source will briefly describe the SC Referral source will briefly describe the SC

process to the familyprocess to the family– Referral sent to the Service Coordinator who Referral sent to the Service Coordinator who

will contact the family within 3 business dayswill contact the family within 3 business days


AssessmentsAssessments– Service Coordinator meets with family to Service Coordinator meets with family to

discuss strengths, needs, and cultural discuss strengths, needs, and cultural issues within 5 business days in an issues within 5 business days in an agreed upon locationagreed upon location

– Reviews the service coordination Reviews the service coordination process in more detailprocess in more detail

– Releases of Information get signedReleases of Information get signed– Family and Service Coordinator work Family and Service Coordinator work

together to identify appropriate TRACK together to identify appropriate TRACK

Local Service Local Service Coordination ProcessCoordination Process

Track 1 – Family Stability Track 1 – Family Stability ModelModel


Track 1 – Family Stability ModelTrack 1 – Family Stability Model

For families with less intensive For families with less intensive needs/less riskneeds/less risk

SC plan created with written/verbal SC plan created with written/verbal feedback from providersfeedback from providers

Family and service coordinator Family and service coordinator responsible for planresponsible for plan

AT LEAST monthly contact until case AT LEAST monthly contact until case closureclosure

Local Service Local Service Coordination ProcessCoordination Process

Track 2 – Family Team Model Track 2 – Family Team Model AKA WRAPAROUNDAKA WRAPAROUND


High-Fidelity WraparoundHigh-Fidelity Wraparound The wraparound process is a way to improve the lives The wraparound process is a way to improve the lives

of children with complex needs and their families. of children with complex needs and their families. It It is not a program or a type of serviceis not a program or a type of service, but a , but a team based planning processteam based planning process used to develop used to develop plans of care that are individualized based on the plans of care that are individualized based on the strengths and culture of the children and their family. strengths and culture of the children and their family.

The plan is needs-driven rather than service-driven, The plan is needs-driven rather than service-driven, although a plan may incorporate existing categorical although a plan may incorporate existing categorical services, if appropriate to meet the needs of the services, if appropriate to meet the needs of the consumer. The initial plan should be a combination of consumer. The initial plan should be a combination of existing or modified services, newly created services, existing or modified services, newly created services, informal supports, and community resources, and informal supports, and community resources, and should include a plan for a step-down of formal should include a plan for a step-down of formal servicesservices

Why Wraparound?Why Wraparound? Intervening effectively with these

young people has proven very difficult and outcomes have been poor. Why?

Children and family needs are complexChildren and family needs are complex Family and youth are rarely fully engaged in Family and youth are rarely fully engaged in

servicesservices Systems work in “silos”Systems work in “silos”

What’s different in What’s different in Wraparound?Wraparound?

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”


Track 2 – Family Team ModelTrack 2 – Family Team Model– Those individuals who have personal or Those individuals who have personal or

professional relationship with the familyprofessional relationship with the family Formal and informal supportsFormal and informal supports

– Review of assessment summaryReview of assessment summary– Safety/crisis planSafety/crisis plan– SC Plan created around PRIMARY SC Plan created around PRIMARY

need(s) and divides responsibilities need(s) and divides responsibilities among groupamong group


Service Coordination PlanService Coordination Plan– Family identifies Family identifies theirtheir long term vision long term vision – Family and team work together to identify and Family and team work together to identify and

plan around immediate needsplan around immediate needs– Family and team clearly identify barriers and Family and team clearly identify barriers and

plan around themplan around them– Family and team incorporate strengths to help Family and team incorporate strengths to help

meet goalsmeet goals– Formal and informal supports incorporatedFormal and informal supports incorporated– Progress is reviewed. Plan is updated as needed.Progress is reviewed. Plan is updated as needed.

Goal of Service CoordinationGoal of Service Coordination Address issues that are impacting family stabilityAddress issues that are impacting family stability Maintain the child in the home when safely able Maintain the child in the home when safely able

to do soto do so Strengthen and empower the child and family Strengthen and empower the child and family

unitunit Connect with community resources and supportsConnect with community resources and supports Ensure that the formal and informal supports are Ensure that the formal and informal supports are

working as a part of a team to help the familyworking as a part of a team to help the family

The Jones Family – Case The Jones Family – Case ExampleExample

Mom and Dad, Tommy and BenMom and Dad, Tommy and Ben Tommy is 12 and was adopted by the Tommy is 12 and was adopted by the

family as a toddler. He is struggling family as a toddler. He is struggling in school and they are considering in school and they are considering unruly charges, he refuses to go to unruly charges, he refuses to go to counseling, and has been physical counseling, and has been physical with 7 year old Ben. The case is with 7 year old Ben. The case is referred by the school social worker.referred by the school social worker.

Case ExampleCase Example Family agrees to Family Team Model due to the Family agrees to Family Team Model due to the

level of crisis, risk of court involvement, potential level of crisis, risk of court involvement, potential placement in Attention Center, etc.placement in Attention Center, etc.

Assessment is completed. Assessment is completed. Strengths – Enjoy camping together, Tommy and Strengths – Enjoy camping together, Tommy and

dad are artistic, marriage is strong dad are artistic, marriage is strong Informal supports – church family, sister-in-law, Informal supports – church family, sister-in-law,

YMCA coachYMCA coach Needs- Failing multiple classes at school, conflict Needs- Failing multiple classes at school, conflict

with principal; transportation (dad’s job is at risk); with principal; transportation (dad’s job is at risk); finances are tight – increases parent stress; manage finances are tight – increases parent stress; manage anger to increase success at school and decrease anger to increase success at school and decrease conflict at homeconflict at home

Case ExampleCase Example Family Team ModelFamily Team Model

– Mom, dad, Tommy, school social worker, teacher, Mom, dad, Tommy, school social worker, teacher, juvenile court representative, church member, sister-juvenile court representative, church member, sister-in-law, YMCA coach come together for a meetingin-law, YMCA coach come together for a meeting

– Review assessment (strengths, needs, cultural Review assessment (strengths, needs, cultural issues)issues)

– Create safety planCreate safety plan– Identify needs and prioritizeIdentify needs and prioritize– Identify and plan around barriers Identify and plan around barriers

– THIS PROCESS IS FACILITATED BY SERVICE THIS PROCESS IS FACILITATED BY SERVICE COORDINATORCOORDINATOR

Case ExampleCase Example Two primary needs as Two primary needs as determined determined

by familyby family= = – School (failing, trouble with principal, School (failing, trouble with principal,

mom called to school constantly, mom called to school constantly, creates conflict with the family, hanging creates conflict with the family, hanging out with the “wrong crowd”)out with the “wrong crowd”)

– Finances (car died, bills going unpaid, Finances (car died, bills going unpaid, dad’s at risk of losing job)dad’s at risk of losing job)

Case ExampleCase Example School –School –

– School personnel indicates Tommy is School personnel indicates Tommy is having most difficulty in math and having most difficulty in math and science and acts out the most during science and acts out the most during and after these two classesand after these two classes

– Mom agrees that Mom agrees that homework/grades/school functioning is homework/grades/school functioning is typically what starts conflicts at hometypically what starts conflicts at home

Case ExampleCase Example Service Coordination Plan - SchoolService Coordination Plan - School

– YMCA coach has a teammate who is studying YMCA coach has a teammate who is studying math/science in college who may tutor Tommymath/science in college who may tutor Tommy

– Church member volunteers to watch Ben so Tommy can Church member volunteers to watch Ben so Tommy can be tutored at home with little distractionsbe tutored at home with little distractions

– School social worker agrees to create behavioral reward School social worker agrees to create behavioral reward system to improve Tommy’s behavior and decrease system to improve Tommy’s behavior and decrease Tommy’s negative interactions with principalTommy’s negative interactions with principal

– YMCA coach willing to have Tommy be statistician for YMCA coach willing to have Tommy be statistician for H.S. soccer team to increase time with positive male role H.S. soccer team to increase time with positive male role models/decrease time with the “wrong crowd”models/decrease time with the “wrong crowd”

– Family and TCFCFC will share the cost of enrolling Family and TCFCFC will share the cost of enrolling Tommy in an art class; Church member will provide Tommy in an art class; Church member will provide transportationtransportation

Case ExampleCase Example Service Coordination Plan- FinancesService Coordination Plan- Finances

– Parents agree to debt Parents agree to debt management/budgeting classesmanagement/budgeting classes

– Parents agree to Ways to Work to help dad Parents agree to Ways to Work to help dad purchase a vehiclepurchase a vehicle

– Sister-in-law agrees to work out Sister-in-law agrees to work out transportation plan so dad can get to worktransportation plan so dad can get to work

– Parents agree to contact JFS regarding Parents agree to contact JFS regarding applying for PASS funding for families of applying for PASS funding for families of adopted children adopted children

Case ExampleCase Example How does this impact the local system?How does this impact the local system?

– There is a financial and emotional cost if There is a financial and emotional cost if Tommy receives charges in Juvenile Court Tommy receives charges in Juvenile Court

– The risk of Tommy being placed in a The risk of Tommy being placed in a specialized school decreases specialized school decreases

– There is a financial and emotional cost if There is a financial and emotional cost if Tommy’s is placed outside of the homeTommy’s is placed outside of the home Cost to the schoolCost to the school Cost to the systemsCost to the systems Cost to Tommy and familyCost to Tommy and family

Case ExampleCase Example The process has supported Dad remaining a The process has supported Dad remaining a

member of the workforcemember of the workforce The process has involved informal supports The process has involved informal supports

to help the family meet some of their needs to help the family meet some of their needs vs. creating a plan that relies on systemsvs. creating a plan that relies on systems

Case ExampleCase Example In between first and second family In between first and second family

team meeting – team meeting – – Service Coordinator Service Coordinator

facilitates enrollment of Tommy in art classfacilitates enrollment of Tommy in art class Contacts school to obtain behavioral plan Contacts school to obtain behavioral plan

and shares with the family’s teamand shares with the family’s team Confirms appointment time for Ways to Confirms appointment time for Ways to

Work and Budgeting meetingWork and Budgeting meeting Verifies progress has been made on tutoring Verifies progress has been made on tutoring

planplan

Case ExampleCase Example Second Family Team Meeting within 10 Second Family Team Meeting within 10

business daysbusiness days– Review family planReview family plan

Meeting occurred for Ways to Work and BudgetingMeeting occurred for Ways to Work and Budgeting School created behavior plan last week – can’t report School created behavior plan last week – can’t report

on progresson progress Art class starts next weekArt class starts next week Coach unable to find tutor for Tommy but he is Coach unable to find tutor for Tommy but he is

helping at the YMCAhelping at the YMCA Family found to be eligible for PASS fundingFamily found to be eligible for PASS funding Dad able to get to work through sister-in-law and co-Dad able to get to work through sister-in-law and co-

workersworkers

Case ExampleCase Example In between second and third meetingsIn between second and third meetings

– Service CoordinatorService Coordinator Verifies Tommy is attending art classVerifies Tommy is attending art class Determines progress with Ways to Determines progress with Ways to

Work/Budgeting meetingWork/Budgeting meeting Works with school to determine progress with Works with school to determine progress with

behavior plan and potential student tutorbehavior plan and potential student tutor Determines progress in involvement with Determines progress in involvement with

Coach/YMCA Coach/YMCA

Case ExampleCase Example Third Family Team MeetingThird Family Team Meeting

– Family and team discuss where progress Family and team discuss where progress has been made and areas of continued has been made and areas of continued concernconcern

– Mom is questioning potential FAS due to Mom is questioning potential FAS due to recent information regarding Tommy’s recent information regarding Tommy’s biological familybiological family

– Service Coordinator updates Family Plan Service Coordinator updates Family Plan to include any additional issues, such as to include any additional issues, such as connection with Health Dept. to learn connection with Health Dept. to learn about FASabout FAS

Case ExampleCase ExampleAs the level of risk and family crisis As the level of risk and family crisis

decreases, Family Team Meetings occur decreases, Family Team Meetings occur less and less frequently.less and less frequently.

Frequency may increase if an additional Frequency may increase if an additional crisis occurs.crisis occurs.

Service Coordination ends when family can Service Coordination ends when family can navigate the system, is not experiencing navigate the system, is not experiencing crisis, risk of removal is decreased, and crisis, risk of removal is decreased, and supports are maintained or no longer supports are maintained or no longer needed. needed.

Questions?Questions? Contact info:Contact info:

Tuscarawas County Family and Tuscarawas County Family and Children First Council - 330-343-2286Children First Council - 330-343-2286

Rindy Brace, Service CoordinatorRindy Brace, Service [email protected]@adamhtc.org

Documents

Service Coordination