1 / 32

Healthy Start Care Coordination

Overview. 1991: Healthy Start Legislation Passed1992: Healthy Start Implemented1993: Family Support Plan Legislation Passed 1994- present: Family Support Planning Process outlined in the Healthy Start Standards and Guidelines. Family Support Plan. ?The

catherine
Download Presentation

Healthy Start Care Coordination

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

    1. Healthy Start Care Coordination Family Support Plans

    2. Overview 1991: Healthy Start Legislation Passed 1992: Healthy Start Implemented 1993: Family Support Plan Legislation Passed 1994- present: Family Support Planning Process outlined in the Healthy Start Standards and Guidelines 1991-1992 Healthy Start (HS) Legislation passed and implemented (FS Chap383.011(section), FAC Chap. 64F-3 (Healthy Start Care Coordination), FAC chap. 64F-2 (Coalitions) 1993 Family Support Planning (FSP) Legislation (FS 411.224). This mandates that FSP process is to be used for individuals and families in the target population. Healthy Start participants in need of ongoing service coordination are specifically named in the statute as a population that is to use a family support planning process. 1994-Present HS Standards and Guidelines incorporate the FSP process. FAC 64F-3 Healthy Start Care Coordination rule chapter defines Family Support Plan and states under on-going care coordination (64F-3.005(3) that a Family Support Plan will be used for intensive coordination of services addressing complex concerns. 1991-1992 Healthy Start (HS) Legislation passed and implemented (FS Chap383.011(section), FAC Chap. 64F-3 (Healthy Start Care Coordination), FAC chap. 64F-2 (Coalitions) 1993 Family Support Planning (FSP) Legislation (FS 411.224). This mandates that FSP process is to be used for individuals and families in the target population. Healthy Start participants in need of ongoing service coordination are specifically named in the statute as a population that is to use a family support planning process. 1994-Present HS Standards and Guidelines incorporate the FSP process. FAC 64F-3 Healthy Start Care Coordination rule chapter defines Family Support Plan and states under on-going care coordination (64F-3.005(3) that a Family Support Plan will be used for intensive coordination of services addressing complex concerns.

    3. Family Support Plan “The written guide resulting from a family-centered planning process jointly prepared by the participant or family and the care coordinator. The plan is the basis for care coordination and identifies the specific concerns, needs and priorities of the client or family, the resources available, and specifies the service objectives that should lead to improved health outcomes.” Chapter 64F-3 Healthy Start Care Coordination In the In the Standards and Guidelines Standard 4.4.c (6) it mentions the two options available for a Family Support Plan. It states: A Family Support Plan for all Level 3 Healthy Start participants using the process of the one page Family Support Plan (DH 3151) or the six page Family Support Plan (DH 3136) when applicable. Healthy Start care coordinators should use the six page form for participants receiving intensive care coordination, multiple services and/or multi-agency involvement and use the “FSP for Single Agency Care Coordination” for participants that do not require intensive service coordination with multiple agencies. The one page form is an internal form used only with HS.In the In the Standards and Guidelines Standard 4.4.c (6) it mentions the two options available for a Family Support Plan. It states: A Family Support Plan for all Level 3 Healthy Start participants using the process of the one page Family Support Plan (DH 3151) or the six page Family Support Plan (DH 3136) when applicable. Healthy Start care coordinators should use the six page form for participants receiving intensive care coordination, multiple services and/or multi-agency involvement and use the “FSP for Single Agency Care Coordination” for participants that do not require intensive service coordination with multiple agencies. The one page form is an internal form used only with HS.

    4. Family Support Plan A Family Support Plan should be developed when multiple agencies are working with an individual/family. If Healthy Start is not the lead care coordination agency, a copy of the participant’s/family’s FSP should be obtained and placed in the HS record. When other agencies are involved, a Family Support Plan may already have been developed. When HS is not the lead agency, the care coordinator should participate in the development of the FSP and obtain a copy of the plan for their record. Children’s Medical Services (CMS) usually has lead responsibility for medically complex children and Department of Children and Families (DCF) usually has lead responsibility for children pending dependency dispositions. However, DCF may share this responsibility with CMS or DOH for substance exposed newborns. Healthy Families is required to do full FSPs with all their clients. When other agencies are involved, a Family Support Plan may already have been developed. When HS is not the lead agency, the care coordinator should participate in the development of the FSP and obtain a copy of the plan for their record. Children’s Medical Services (CMS) usually has lead responsibility for medically complex children and Department of Children and Families (DCF) usually has lead responsibility for children pending dependency dispositions. However, DCF may share this responsibility with CMS or DOH for substance exposed newborns. Healthy Families is required to do full FSPs with all their clients.

    5. The Healthy Start Single Agency Family Support Plan is roughly the equivalent of page 4 (Activity Plan) of the original Family Support Plan. It was developed for use with participants in HS who are in need of ongoing care coordination but will be receiving services from only one agency that uses the FSP. This does not mean that all components of the FSP are not required. Identification of the pregnant woman’s strengths, concerns, priorities and resources is an integral part of the single agency FSP and should be documented in the initial assessment. In no case should a family have a single agency and a multiagency FSP; if other agencies who would use the FSP are involved, then the multi-agency form is used. The Healthy Start Single Agency Family Support Plan is roughly the equivalent of page 4 (Activity Plan) of the original Family Support Plan. It was developed for use with participants in HS who are in need of ongoing care coordination but will be receiving services from only one agency that uses the FSP. This does not mean that all components of the FSP are not required. Identification of the pregnant woman’s strengths, concerns, priorities and resources is an integral part of the single agency FSP and should be documented in the initial assessment. In no case should a family have a single agency and a multiagency FSP; if other agencies who would use the FSP are involved, then the multi-agency form is used.

    6. A Family Support Plan….. …makes the participant and provider a TEAM ….clarifies every person’s roles …allows the participant to be the “author”, and the care coordinator to be the “scribe”. Healthy Start is not here to “do something to them” but is here to work together with the participant and family to address their concerns that may effect the pregnant woman’s health and the baby’s health. Families need to feel like partners (active not passive). The participant needs to feel ownership of his or her FSP. Even if the baby is the client, the mom will write goals for the benefit of the baby. Again the FSP is the family’s plan. It should be written in language easily understood by the family. These goals/ dreams must be written because if they are not, they become only intentions that could easily be forgotten. So, a copy of the FSP is given to the family. (Caution watch “wording” because the plan is out in the open for everyone to see…..participant writes plan) Healthy Start is not here to “do something to them” but is here to work together with the participant and family to address their concerns that may effect the pregnant woman’s health and the baby’s health. Families need to feel like partners (active not passive). The participant needs to feel ownership of his or her FSP. Even if the baby is the client, the mom will write goals for the benefit of the baby. Again the FSP is the family’s plan. It should be written in language easily understood by the family. These goals/ dreams must be written because if they are not, they become only intentions that could easily be forgotten. So, a copy of the FSP is given to the family. (Caution watch “wording” because the plan is out in the open for everyone to see…..participant writes plan)

    7. Benefits of a Family Support Plan ..models goal setting behavior and problem solving …promotes a way to enhance and acknowledge self direction which leads to self sufficiency ..increases the chance of families making behavioral changes …gives a sense of satisfaction and progress to both the participant and the provider Families who may be overwhelmed with meeting their basic needs can be helped by showing them: How to break their concerns down to manageable units; how to think through what they want; and how to explore options and take action. A FSP can also help a participant organize and prioritize ( ex: using a calendar to remember appointments) This is what is unique about this approach. It conveys to the participant / family:“You can make decisions, you can be in control.” This is what Healthy Start is about. Families can make changes when they: understand the issues better; set their own priorities; explore options including resources; problem solve; know what is expected of them; know what to expect from HS; have reinforcement at each encounter; and feel like they have control. REMEMBER: Behavior change comes from internal motivation.FSP defines what success is and it reinforces and validates actions and accomplishments. It also provides a measure (benchmark) as a way of celebrating steps along the way. It allows success to be celebrated incrementally. Small steps are important: “Finishing their GED might be too big of a goal BUT enrolling and attending a GED class might be less scary. Families who may be overwhelmed with meeting their basic needs can be helped by showing them: How to break their concerns down to manageable units; how to think through what they want; and how to explore options and take action. A FSP can also help a participant organize and prioritize ( ex: using a calendar to remember appointments) This is what is unique about this approach. It conveys to the participant / family:“You can make decisions, you can be in control.” This is what Healthy Start is about. Families can make changes when they: understand the issues better; set their own priorities; explore options including resources; problem solve; know what is expected of them; know what to expect from HS; have reinforcement at each encounter; and feel like they have control. REMEMBER: Behavior change comes from internal motivation.FSP defines what success is and it reinforces and validates actions and accomplishments. It also provides a measure (benchmark) as a way of celebrating steps along the way. It allows success to be celebrated incrementally. Small steps are important: “Finishing their GED might be too big of a goal BUT enrolling and attending a GED class might be less scary.

    8. Family Support Plans Should be offered to all Healthy Start participants who receive on-going, intensive care coordination Usually required for participants with safety concerns and immediate needs Required for all Level 3 participants Knowledge or suspicion of: Domestic violence, Sexual abuse, Other threatened violence, including child abuse, Substance abuse Untreated mental illness including severe depression, suicidal tendencies Known history of abuse and neglect in family/household Infant whose mother received no prenatal care HIV Positive/Hepatitis B Positive Lack of basic needs such as housing and food, Lack of health care including prenatal care Inappropriate growth and development Other, using professional judgment Most participants with these kinds of safety concerns and needs should at least start out being leveled at a 3. If, after assessment, it is determined that they have good strengths and resources to offset their risk, then the level can be reduced. Standard 4.15 All Healthy Start participants assigned a level 3 will have a Family Support Plan. Standard 12.7.a requires the initiation of a family support plan as part of a comprehensive home assessment of substance exposed newborns The process can be used with all HS participants but may only be coded in the HMC system for level 3 participants.Knowledge or suspicion of: Domestic violence, Sexual abuse, Other threatened violence, including child abuse, Substance abuse Untreated mental illness including severe depression, suicidal tendencies Known history of abuse and neglect in family/household Infant whose mother received no prenatal care HIV Positive/Hepatitis B Positive Lack of basic needs such as housing and food, Lack of health care including prenatal care Inappropriate growth and development Other, using professional judgment Most participants with these kinds of safety concerns and needs should at least start out being leveled at a 3. If, after assessment, it is determined that they have good strengths and resources to offset their risk, then the level can be reduced. Standard 4.15 All Healthy Start participants assigned a level 3 will have a Family Support Plan. Standard 12.7.a requires the initiation of a family support plan as part of a comprehensive home assessment of substance exposed newborns The process can be used with all HS participants but may only be coded in the HMC system for level 3 participants.

    9. Enabling Model of Helping Enable families Empower families Strengthen families Strengthen family ties to informal support networks Encourage development of new skills and competencies Source: Bennett, et. al., Developing Individualized Family Support Plans, 1990. Enable families – creating opportunities and providing support for the family or individual to become more competent and independent in their efforts to meet their own needs and achieve their own goals. Empower families – carrying out interventions in such a way that the family members experience a sense of increased control over their lives as a result of their own efforts and successes Strengthen families – helping families to identify the things they already do well and encouraging them to use these capabilities to meet their present needs and future goals Strengthen family ties to informal support networks – strong relationships between the family and informal sources of support give the family greater control over their own lives since this is support the family can access as needed. Encourage the development of new skills and competencies – providing the family with the information, direction and encouragement to develop new strengths and become more independent and self reliant.Enable families – creating opportunities and providing support for the family or individual to become more competent and independent in their efforts to meet their own needs and achieve their own goals. Empower families – carrying out interventions in such a way that the family members experience a sense of increased control over their lives as a result of their own efforts and successes Strengthen families – helping families to identify the things they already do well and encouraging them to use these capabilities to meet their present needs and future goals Strengthen family ties to informal support networks – strong relationships between the family and informal sources of support give the family greater control over their own lives since this is support the family can access as needed. Encourage the development of new skills and competencies – providing the family with the information, direction and encouragement to develop new strengths and become more independent and self reliant.

    10. Family Support Planning Guidelines Base interventions on needs and aspirations identified by individual/family Promote use of existing strengths and capabilities Emphasize importance of developing strong support network Expand and develop repertoire of skills and competencies Source: Bennett, et. al., Developing Individualized Family Support Plans, 1990. The family must be willing to put its own time and energy into an effort to bring about change. All families have strengths and capabilities, even though they may not recognize them. Using their own resources to find solutions builds confidence and self esteem. Strong relationships with a supportive network are critical to the development of a healthy family unit. Care coordinators need to employ helping behaviors which create opportunities for individuals/families to develop skills to meet their need and achieve their desired goals. The family must be willing to put its own time and energy into an effort to bring about change. All families have strengths and capabilities, even though they may not recognize them. Using their own resources to find solutions builds confidence and self esteem. Strong relationships with a supportive network are critical to the development of a healthy family unit. Care coordinators need to employ helping behaviors which create opportunities for individuals/families to develop skills to meet their need and achieve their desired goals.

    11. Healthy Start Care Coordinators Identify/evaluate/assess in collaboration with the family, their strengths, resources, needs and priorities Address identified risks and needs Provide information, education and encouragement to motivate clients to change situations placing them at risk Promote self sufficiency and healthy outcomes Make maximum use of community resources Collaborate with other service providers Advocate on behalf of participant When you look at the care coordination activities outlines in the standards and guidelines, you can see that these are the same activities used in family support planning. The family centered planning process is the basis for Healthy Start care coordination regardless of whether or not the actual form is used.When you look at the care coordination activities outlines in the standards and guidelines, you can see that these are the same activities used in family support planning. The family centered planning process is the basis for Healthy Start care coordination regardless of whether or not the actual form is used.

    12. FSP is Part of the Care Coordination Process The information obtained from the Healthy Start screen, initial contact and initial assessment is used to develop a plan of care that includes a Family Support Plan. The Family Support Plan is key to involving the family in their plan of care.

    13. How Do We Get to the FSP? 1st step - Initial Contact and development of the Initial Plan of Care 2nd step - Initial Assessment 3rd – On-going care coordination/ family support planning. Family Support Planning starts after or during the initial assessment and focuses on issues identified by the care coordination assessment and on issues identified by the family. Always document if a family doesn’t want to focus on an identified issue. The connection between assessment and the family support plan is pivotal: Issues are discussed, Options are explored; families problem solve and set goals. Lets look at this delineation: The Initial Contact establishes with the family the purpose of Care Coordination which is to have a healthy mother and a healthy baby . The Initial Assessment identifies risks which may contribute to a poor birth outcome and interfere with the infant’s health and development. The Family Support Planning process phase clarifies those issues and helps families decide what issues they would like to address. It involves the family in goal setting and determining how they want to go about trying to reach their goals. It clarifies their role and the Healthy Start Care Coordinator’s role and let’s them know what to expect at each visit. Family Support Planning starts after or during the initial assessment and focuses on issues identified by the care coordination assessment and on issues identified by the family. Always document if a family doesn’t want to focus on an identified issue. The connection between assessment and the family support plan is pivotal: Issues are discussed, Options are explored; families problem solve and set goals. Lets look at this delineation: The Initial Contact establishes with the family the purpose of Care Coordination which is to have a healthy mother and a healthy baby . The Initial Assessment identifies risks which may contribute to a poor birth outcome and interfere with the infant’s health and development. The Family Support Planning process phase clarifies those issues and helps families decide what issues they would like to address. It involves the family in goal setting and determining how they want to go about trying to reach their goals. It clarifies their role and the Healthy Start Care Coordinator’s role and let’s them know what to expect at each visit.

    14. IPC vs FSP Care Coordinator’s plan of interventions to reduce risks Developed for all clients Developed during IC and updated after each visit Participant/family’s plan for how they will accomplish their goals Developed for all Level 3 clients Developed during or after IA and updated every 3 months or as needed

    15. IPC vs FSP (cont.) Can be written as “P” in SOAP note or written in narrative format and identified as IPC Does not require client signature Recorded on FSP for Single Agency Care Coordination form 3151 or multi-agency FSP form 3136 Requires client signature

    16. Family Support Planning Should be initiated after or during the initial assessment for Level 3 participants and others as needed. The HS Care Coordinator serves at the single point of contact for the family, working across agency lines to ensure that the priorities of each family are met. For the single agency FSP, the care coordinator and the participant will address risks that could affect birth outcome and child’s development.For the single agency FSP, the care coordinator and the participant will address risks that could affect birth outcome and child’s development.

    17. Healthy Start Initial Assessment Face to face evaluation done in collaboration with the participant and family to further identify and explore: 1) Factors that may negatively affect the pregnancy or the child’s or mother’s health 2) Participant and family concerns, priorities, strengths and resources 3) Barriers to health care and other services For pregnant women, assessment may be related to her understanding of the psychosocial and environmental risk factors related to pregnancy, nutritional assessment or other evaluations related to increasing positive birth outcomes.For pregnant women, assessment may be related to her understanding of the psychosocial and environmental risk factors related to pregnancy, nutritional assessment or other evaluations related to increasing positive birth outcomes.

    18. Assessment Process Ongoing vs. one time Should contain more than a laundry list of problems Should identify strengths and successes (what’s working) Should convey respect for values and culture of individual/family Culturally sensitive: Families come from different cultures and ethnic groups. Families reflect their diversity in their views and expectations of themselves, of their children, and of professionals. Services should be provided in ways that are sensitive to these variants and consistent with family values and beliefs. Culturally sensitive: Families come from different cultures and ethnic groups. Families reflect their diversity in their views and expectations of themselves, of their children, and of professionals. Services should be provided in ways that are sensitive to these variants and consistent with family values and beliefs.

    19. Concerns Circumstances or areas which worry, distress or create difficulties for individuals/families Areas that do not fulfill dreams or expectations Interest in things being better or different Source: Duwa, S. “Developing Family Support Plans Participant Handbook,” 1995. Possible areas of concern: developmental issues, social/community supports, health, pregnancy, parent support, child care, education, budgeting, transportation, shelter/food, employment, legal assistance, etc. Possible areas of concern: developmental issues, social/community supports, health, pregnancy, parent support, child care, education, budgeting, transportation, shelter/food, employment, legal assistance, etc.

    20. Family Resources and Strengths Categories of Resources: Personal qualities Interpersonal capacities Family attributes Concrete assets Informal support networks Formal support systems Source: Duwa, S. “Developing Family Support Plans Participant Handbook,” 1995 Resources are people, skills and capacities, the relationships and concrete assets which support, nurture and sustain family Personal qualities – persistence, hopefulness, sense of humor, reliability, ability to ask for and use help, resilience Interpersonal capacities - ability to relate well to people, listen well, to provide support Family attributes – attitudes, beliefs, coping styles, traditions,, support Concrete assets – finances, transportation, housing, employment Informal support – friends, relatives, neighbors, co-workers and groups (churches, social clubs, parent organizations) Formal support – professionals (physicians, clergy, therapists) agencies, and educational programsResources are people, skills and capacities, the relationships and concrete assets which support, nurture and sustain family Personal qualities – persistence, hopefulness, sense of humor, reliability, ability to ask for and use help, resilience Interpersonal capacities - ability to relate well to people, listen well, to provide support Family attributes – attitudes, beliefs, coping styles, traditions,, support Concrete assets – finances, transportation, housing, employment Informal support – friends, relatives, neighbors, co-workers and groups (churches, social clubs, parent organizations) Formal support – professionals (physicians, clergy, therapists) agencies, and educational programs

    21. Sources of Information Verbal interactions with participants Observation of home environment Observation of family interaction Information from other service providers How do we identify family resources and strengths? There are multiple sources of information we can use. Observation: Family members may present few strengths directly but may display strengths through actions – listening respectfully, working on a project together shows commitment to working together. The physical environment may include homemade crafts or decorations, special care given to educating children. Descriptions of daily routines may reveal coping styles for dealing with fun and not so fun tasks. Listen to family stories – look at photo albums Collateral contacts: How do we identify family resources and strengths? There are multiple sources of information we can use. Observation: Family members may present few strengths directly but may display strengths through actions – listening respectfully, working on a project together shows commitment to working together. The physical environment may include homemade crafts or decorations, special care given to educating children. Descriptions of daily routines may reveal coping styles for dealing with fun and not so fun tasks. Listen to family stories – look at photo albums Collateral contacts:

    22. Interviewing Skills Attending behavior Open versus closed questions Client observation skills Encourage, paraphrase and summarize Reflection of feeling Attending behavior – eye contact, relaxed position, express interest in facial expression Open vs closed questions – asking questions that encourage the person to tell you more rather than one word answers “Are you getting along ok?” closed – “Tell me about how you are getting along.” Observing interaction between family members, family routines Respect silences – this encourages the client to continue Incorporate words and expression that the family uses Reflect the feelings underneath the words. “It sounds like you are pretty frustrated with how long you have had to wait for an appointment” of I’m wondering if you are concerned about how you are going to get to your appointment.” A speculative approach is very effective and invites the client to confirm what they are feeling or correct your impression both of which lead to increased understanding.Attending behavior – eye contact, relaxed position, express interest in facial expression Open vs closed questions – asking questions that encourage the person to tell you more rather than one word answers “Are you getting along ok?” closed – “Tell me about how you are getting along.” Observing interaction between family members, family routines Respect silences – this encourages the client to continue Incorporate words and expression that the family uses Reflect the feelings underneath the words. “It sounds like you are pretty frustrated with how long you have had to wait for an appointment” of I’m wondering if you are concerned about how you are going to get to your appointment.” A speculative approach is very effective and invites the client to confirm what they are feeling or correct your impression both of which lead to increased understanding.

    23. Tools for Identifying Strengths and Needs ECO Map Strength Inventory from Partners for a Healthy Baby Home Visiting Process Family Needs Scale Tell Us About Yourself Questionnaire Developmental screening tools Formal screening tools such as the Ages and Stages Questionnaire are useful in identifying infant strengths and needs.Formal screening tools such as the Ages and Stages Questionnaire are useful in identifying infant strengths and needs.

    24. Eco Map

    25. Goals/Outcomes Should reflect the changes family members want to see for themselves or their child, not the behaviors or actions that professionals think should occur Are based on family priorities and concerns and all information gathered during assessment Should mobilize the family’s own resources and network of support The goal is the end result that the person is trying to achieve. Examples of outcomes: I would like to be prepared for the birth of my child I would like to bring my baby home to a safe neighborhood I would like to learn how to take good care of my baby I would like for my baby to have a relationship with his/her fatherThe goal is the end result that the person is trying to achieve. Examples of outcomes: I would like to be prepared for the birth of my child I would like to bring my baby home to a safe neighborhood I would like to learn how to take good care of my baby I would like for my baby to have a relationship with his/her father

    26. S.M.A.R.T State exactly what the family wants to happen Goals should be measurable (observable) Goals should be achievable and realistic Include target dates for each objective or step toward the goal Source: “Advanced FSP Training” Healthy Families Florida Training Institute Also help participant think about what might get in the way or prevent her what getting what she wants for herself or her child. Also help participant think about what might get in the way or prevent her what getting what she wants for herself or her child.

    27. Questions to Assist with Goal Setting Miracle Question – What would your life look like tomorrow if a miracle happened while you were asleep and your situation is taken care of? How would things be different for you or for your child? Scaling Question – on a scale from 1-10 how would you rate your . . . ? Sometimes participants need help figuring out what they want to change or accomplish. These types of questions encourage an alternative way of thinking about their situation and can open up new possibilities for change. With the scaling question, it can also help to assess how much of a problem it is for the person. One the person rates the problem, then you can ask, “What would it take for you to get it to a . . . ? Not only can this make the problem seem more manageable (gradual change vs. complete elimination of problem but it can help to identify some of the steps that would need to be taken to resolve the problem.Sometimes participants need help figuring out what they want to change or accomplish. These types of questions encourage an alternative way of thinking about their situation and can open up new possibilities for change. With the scaling question, it can also help to assess how much of a problem it is for the person. One the person rates the problem, then you can ask, “What would it take for you to get it to a . . . ? Not only can this make the problem seem more manageable (gradual change vs. complete elimination of problem but it can help to identify some of the steps that would need to be taken to resolve the problem.

    28. Problem Solving Process Problem identification Goal selection Generating solutions Considering consequences Decision making Implementation Evaluation “What is my problem?” “What do I want?” “What can I do?” “What will happen if . . . ?” “What is my decision?” “I’m going to do it.” “Did I meet my goal?” Step 1 – help participant identify in specific words what the concern or problem is. Ask direct questions such as “How serious a problem is this for you?” Step 2 – It is not enough to identify a situation as a problem. The person needs to say that it is something she wants to change. She also needs to decide what outcomes she wants. Assess readiness for change – should I do this now? How can I get ready to make this change? Step 3 – Help the participant think of several different solutions before making a decision. Step 4 – Help the participant think about what might happen as a result of each solution. What am I afraid will happen if I do thins? What might prevent the strategy from working? Step 5 – Help the participant decide which of the possible solutions she is going to implement. Acknowledge that change can be scary. Step 6 – Help the person to commit. “This is what I am going to do and this is how I am going to do it.” Decide what supports will be needed to implement solution. Step 7 – Once the strategy has been implemented, have the person ask,”Did my strategy help me to meet my goal? Was I successful?Step 1 – help participant identify in specific words what the concern or problem is. Ask direct questions such as “How serious a problem is this for you?” Step 2 – It is not enough to identify a situation as a problem. The person needs to say that it is something she wants to change. She also needs to decide what outcomes she wants. Assess readiness for change – should I do this now? How can I get ready to make this change? Step 3 – Help the participant think of several different solutions before making a decision. Step 4 – Help the participant think about what might happen as a result of each solution. What am I afraid will happen if I do thins? What might prevent the strategy from working? Step 5 – Help the participant decide which of the possible solutions she is going to implement. Acknowledge that change can be scary. Step 6 – Help the person to commit. “This is what I am going to do and this is how I am going to do it.” Decide what supports will be needed to implement solution. Step 7 – Once the strategy has been implemented, have the person ask,”Did my strategy help me to meet my goal? Was I successful?

    29. Action Plan/Resources/Services List strategies, activities and services that will result in the achievement of outcomes. Include family, individuals and agencies responsible for each action or available as resources. Include the specific services that will be provided, the frequency provided and provider. Include criteria and timelines for evaluating achievement of outcomes. What are the steps required to accomplish the goal? Encouraging a family to employ its own support network enhances family functioning and reduces the possibility of dependence on the service system. Example: Goal is to quit smoking Strategies or Steps to accomplish the goal: Find out about community resources to assist with quitting Choose which services to utilize Identify other sources of support that will be utilized i.e. friends, family, Quit Line Establish target date for quitting or cutting back Each strategy or step should have a target date for completion. What are the steps required to accomplish the goal? Encouraging a family to employ its own support network enhances family functioning and reduces the possibility of dependence on the service system. Example: Goal is to quit smoking Strategies or Steps to accomplish the goal: Find out about community resources to assist with quitting Choose which services to utilize Identify other sources of support that will be utilized i.e. friends, family, Quit Line Establish target date for quitting or cutting back Each strategy or step should have a target date for completion.

    30. Family Support Planning Follow Up Evaluate steps taken or not taken at each visit Encourage and support steps accomplished Evaluate progress toward goals Decide together what needs to happen next Modify plan as needed and update at least every 3 months At each encounter, evaluation is made of progress toward achieving the stated goals. The plan should be modified as needed and updated at least every three months. Updates do not have to be face to face unless participant assessment is necessary to evaluate goals. If done via telephone, assure that a copy of the update is sent to the participant in the mail. Celebrate successes. Evaluation is important because it assures that risk factors continue to be addressed and it provides an opportunity to revise strategy and continues problem solving. Remember to praise your clients for their success no matter how small it is, and try not to be overly critical. You do not walk in their shoes. Explore the barriers and help them find other options. Decide what needs to happen…you guide the client but it is still the client’s goals/ dreams….its what she wants for herself not what you want for her !!! At each encounter, evaluation is made of progress toward achieving the stated goals. The plan should be modified as needed and updated at least every three months. Updates do not have to be face to face unless participant assessment is necessary to evaluate goals. If done via telephone, assure that a copy of the update is sent to the participant in the mail. Celebrate successes. Evaluation is important because it assures that risk factors continue to be addressed and it provides an opportunity to revise strategy and continues problem solving. Remember to praise your clients for their success no matter how small it is, and try not to be overly critical. You do not walk in their shoes. Explore the barriers and help them find other options. Decide what needs to happen…you guide the client but it is still the client’s goals/ dreams….its what she wants for herself not what you want for her !!!

    31. SUMMARY Family Support Plan is PARTICIPANT CENTERED provides a Road Map for the participant and family is an ongoing dynamic, interactive process that does not end is a discussion point at every visit should be the guiding force of your work with any family Last three points’ elaboration. ROAD MAP Serves as an agenda for interaction with the client. Interactive process: Plans change; life events change these are opportunities to teach participants to be flexible and “regroup” when necessary. Use this opportunity to talk about resilience. The FSP provides a discussion point at each visit. Also helps in documentation that risk factors are addressed at each visit. Last three points’ elaboration. ROAD MAP Serves as an agenda for interaction with the client. Interactive process: Plans change; life events change these are opportunities to teach participants to be flexible and “regroup” when necessary. Use this opportunity to talk about resilience. The FSP provides a discussion point at each visit. Also helps in documentation that risk factors are addressed at each visit.

    32. The Key A Family Support Plan….. …is the family’s plan that helps them create and live their own goals / DREAMS Keep in mind that this is the family’s plan !! They need to be encouraged to envision a healthier situation for themselves. Using the word “Dream” instead of “goal “ would probably be more understandable. You can ask questions to draw them in (can be difficult), EX a technique that a social worker has used was: “Think back to when you were 5 years old, what was one of your dreams of what your life would be like when you grew up?” (ex finish school) (RED FLAGS) if they can’t think back that far…blank a major feeling of hopelessness….(could be an indication of abuse) Might need outside additional assistance They can dream big and then break down into manageable steps. Keep in mind that this is the family’s plan !! They need to be encouraged to envision a healthier situation for themselves. Using the word “Dream” instead of “goal “ would probably be more understandable. You can ask questions to draw them in (can be difficult), EX a technique that a social worker has used was: “Think back to when you were 5 years old, what was one of your dreams of what your life would be like when you grew up?” (ex finish school) (RED FLAGS) if they can’t think back that far…blank a major feeling of hopelessness….(could be an indication of abuse) Might need outside additional assistance They can dream big and then break down into manageable steps.

    33. Remember an FSP…. MAKES CARE COORDINATION EASIER !!! The family Support Plan becomes the “road map” that directs service delivery. The FSP helps the care coordinator keep interactions and interventions goal oriented, based upon the participant’s priorities and concerns. The FSP provides a vehicle for assisting HS participants in determining what supports they need to enhance their own or their infant’s health and development. It provides a picture of the families priorities and goals and the supports and services they expect to be mobilized to help them meet their goals. It provides a measure of success and a way to identify places in which the participant may be “stuck” The family Support Plan becomes the “road map” that directs service delivery. The FSP helps the care coordinator keep interactions and interventions goal oriented, based upon the participant’s priorities and concerns. The FSP provides a vehicle for assisting HS participants in determining what supports they need to enhance their own or their infant’s health and development. It provides a picture of the families priorities and goals and the supports and services they expect to be mobilized to help them meet their goals. It provides a measure of success and a way to identify places in which the participant may be “stuck”

More Related