A Case of Collaboration Across Systems: The Single Coordinated Case Plan

1. A Case of Collaboration Across Systems: The Single Coordinated Case Plan Francine Feinberg, Psy.D. and Patricia Aniakudo, MS Meta House, Inc. Acknowledgement goes to the State of Wisconsin, Department of Health and Family Services and the Management Group, Inc. for their support and information.

2. Using the Single Coordinated Care Plan (SCCP) Go to: www.tmg-wis.com You will find: • Introduction to the SCCP • SCCP Process Guide • SCCP Forms and Instructions • SCCP Release Forms and Instructions • Other information about the history, performance measurement and local participants.

3. Handouts • Barriers • Core Values • Child Welfare Stipulations • Rules of Supervision • TANF Employment Plan • SCCP forms

4. Systems and their focus • Child Protection – safety and health of children • Substance abuse/mental health – the reduction/cessation of substance abuse and the reduction/cessation of symptoms • TANF – employment and economic independence • Criminal Justice – Public Safety and reducing recidivism

5. Systems differ in many ways • Goals • Expectations and requirements for success • Definition of success based on its own outcomes • Funding sources and accountability requirements

6. Coordination challenges • While workers may be well trained to understand their own system, they may not have a good understanding of other systems. • Front line staff in each system develop plans for the consumer without consideration to other plans being developed for the same consumer in other systems • There may be little or no sharing of information between systems or it may be left to the consumer to carry information between systems.

7. Result • Multiple meetings for client; sometimes scheduling conflicts • Requirements to receive same service from multiple providers • Frenetic pace to meet all requirements • Client required to do the impossible • Failure blamed on client resulting in severe consequences.

8. Meet Paula • Homeless – living in a shelter • Recently released from prison • One child in foster care (age 3) • One child with her (age 10) • Constantly feels anxious, cries easily, has difficulty concentrating • Substance use disorder – alcohol, cocaine, heroin

9. Child Welfare stipulations for reunification • Stay in touch and cooperate with worker, meet with worker weekly to check progress • Have a safe, suitable and stable home • Have regular successful visits with your child • Call child regularly • Complete a psych evaluation • Complete programs recommended by evaluation • Resolve all criminal charges and cooperate with probation officer • Complete: • AODA program – have negative urine tests • Parenting program • Nurturing program • Anger Management • Have successful extended visits

10. Rules of Community Supervision • Avoid contact with XX (Father of 3 year old & criminal partner) • Complete AODA program and sign consent to release information to your agent • Get a mental health evaluation and follow-through on recommendations • Provide urine for analysis • Meet with officer weekly • Attend anger management classes • Obtain employment • Pay restitution, fines and supervision and court fees • Obtain safe housing

11. TANF Employment Plan • Basic Education/GED Hrs/wk: 10 • Employment Search Hrs/wk: 15 • Ongoing Dr. appts Hrs/wk: 5 • Report to worker weekly

12. Wisconsin INITIATIVE inMilwaukee – State Partners • Department of Workforce Development • Division of Economic Support • Department of Health and Family Services • Division of Supportive Living • Child and Family Services • Health Care Finance

13. Process to Identify Barriers Three groups Consumer perspective System perspective Funding impact Participants Consumers HMO’s MH/AODA agencies Milw. Cty gov. TANF agencies State gov. Child Welfare Agencies Gen. Comm. Wraparound Milw.

14. Identified Barriers • Consumers are involved in multiple systems • Separate goals • Timelines • Expectations • Lack coordination • Communication

15. Identified Barriers • Systems lack consumer focus • viewed as recipients of discrete services not as whole people • viewed as having deficits • lack of trust and understanding between consumers and the systems.

16. Identified Barriers • The approach sometimes reflects societal stigmas toward people with mental health and substance abuse issues.

17. Identified Barriers • The assessment and treatment system is not designed to adequately meet the needs of women who have complex mental health and substance abuse issues. • Funding source structure and administration do not support consumer focus and achievement of outcomes.

18. Transformation of Service Delivery • Develop an integrated service network that assists families in gaining self-sufficiency by building upon their strengths and supporting them through formal and informal service networks.

19. Collaboration across funding streams Team Approach across systems Family centered and strengths based plans Consumer involvement at all levels Gender and Culturally responsive plans and services Sustain system change over time SYSTEM OUTCOMES

20. COREVALUES • Family-Centered • Consumer Involvement • Builds on Natural and Community Strength-Based • Unconditional Care • Collaboration Across Systems • Team Approach Across Agencies • Ensuring Safety • Gender/Age/Culturally Responsive Treatment • Self-sufficiency • Education and Work Focus • Belief in Growth, Learning, and Recovery • Outcome-oriented

21. Strength-Based Focus • What does she have - rather than what she does not have • What can she do - rather than what she cannot do • What has she been successful at rather than how she has failed

22. Assumptions in Strength-Based focus • Everyone has strengths • People are experts on themselves • Everyone deserves to be treated with respect and dignity • People can make well-informed decisions when they are supported • When people are involved in decisions about them the outcomes can improve • A team is often more capable of creative and high quality decision making than an individual

23. The Single Coordinated Care Plan • A team-based, family-centered care planning process to help clients achieve improved outcomes. • Care teams • consumer • facilitator • system representatives • friends • family • other support people

24. Principles • The consumer is central to the process • focuses on the consumer's needs • simultaneously addressing the requirements and mandates of each system • Builds on the consumer's vision and strengths • help the consumer meet her needs, as she defines them • all participants work together to help the consumer meet her needs

25. Principles • Built around natural supports • Systems should fill the gaps • Everyone on the SCCP team is accountable for doing his/her part. • Goal is to help the consumer achieve self-sufficiency in meeting life goals.

26. Getting Started Identify who will be at the team meetings • Ideal • Many people formal and informal supports • Reality • Women with SUD’s often have no family, friends or community support when starting process • Not everyone can come to every meeting from all the systems

27. Developing the plan • Roles: • Facilitator • Paula • Child Welfare • Parole Officer • TANF worker • AODA counselor • Brother

28. SINGLE COORDINATED CARE PLAN (SCCP)