WrapCT Presents: PLANNING AND MANAGING TRANSITIONS

1. WrapCTPresents:PLANNING AND MANAGING TRANSITIONS

2. 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

3. 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

4. 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

5. Families deserve to know they are transitioning to something rather than away from something

6. 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 exit

7. 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

8. The Four Phases of the Wraparound Process – Transition Focused Engagement – Learning about the family’s support system Planning – Bringing existing supports in and deciding how to build new supports Implementation – Building bridges to the community, enhancing or enlarging competency, creating opportunities for a better life Transition – Help is in place. Team is mobilized to act when needed.

9. 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

10. Connections and Support Map Family Friends Self Community Work/School

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.

18. 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.

19. 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

20. 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

21. 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

22. Third Phase: Managing ongoing Plan of Care Meetings Accomplishments – Check with family first Assess progress – Check for needs met not just services delivered Adjust the plan – Remember you are planning for transition Assign new tasks – Use the team!

23. 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

24. 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

25. 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

26. 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 & team

27. 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

28. 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

29. 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

30. 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

31. 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

32. Transition: Challenges and Solutions Activity

33. WrapCTLearning CollaborativeOur 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