Service Coordination

1. Service Coordination Tuscarawas County Family and Children First Council

2. Family and Children First Councils • BRIEF overview • Established in statue in 1993 (ORC 121.37) • Local Council in each of the 88 counties with the charge of:

3. Tuscarawas County Family and Children First Council Structure Governing Board Administrative Agent Service Coordinator Service Coordination Committee Budget Committee Advisory Committee Council Function i.e. ACAP Council Function i.e. OCTF Council Function i.e. HMG Council Manager

4. Coordinating Systems and Services =Service Coordination

5. Coordinating Systems and Services =Service Coordination • Service Coordination Guidance Document • Identifies “have to”s of SC process including: • Diversion of children from Juvenile Court • Meeting before out-of-home placements • Monitoring children in out-of-home placements • Service coordination is for any child age 0-21 with “multi-systemic needs”

6. Local Service Coordination Flowchart Referral and Release of information to Service Coordinator Three business days 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 Five business days Assessment completed with family. Safety Plan Created. Ten business days 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. Ongoing meetings at prescribed times with team and supports present to review and update plan. Case Closure. (is stability maintained? Or is family still engaged?, etc.) Ten business days Ten business days

7. Local Service Coordination Process • Referrals • Come from anyone (parent, provider, school, etc.) • Shortened process (1 ½ pages / checkboxes) • Release of information needed • Referral source will briefly describe the SC process to the family • Referral sent to the Service Coordinator who will contact the family within 3 business days

8. Local Service Coordination Process • Assessments • Service Coordinator meets with family to discuss strengths, needs, and cultural issues within 5 business days in an agreed upon location • Reviews the service coordination process in more detail • Releases of Information get signed • Family and Service Coordinator work together to identify appropriate TRACK

9. Local Service Coordination Process Track 1 – Family Stability Model

10. Local Service Coordination Process • Track 1 – Family Stability Model • For families with less intensive needs/less risk • SC plan created with written/verbal feedback from providers • Family and service coordinator responsible for plan • AT LEAST monthly contact until case closure

11. Local Service Coordination Process Track 2 – Family Team Model AKA WRAPAROUND

12. Local Service Coordination Process • High-Fidelity Wraparound • The wraparound process is a way to improve the lives of children with complex needs and their families.  It is not a program or a type of service, but a team based planning process used to develop plans of care that are individualized based on the strengths and culture of the children and their family.  • The plan is needs-driven rather than service-driven, although a plan may incorporate existing categorical services, if appropriate to meet the needs of the consumer.  The initial plan should be a combination of existing or modified services, newly created services, informal supports, and community resources, and should include a plan for a step-down of formal services

13. Why Wraparound? • Intervening effectively with these young people has proven very difficult and outcomes have been poor. Why? • Children and family needs are complex • Family and youth are rarely fully engaged in services • Systems work in “silos”

14. What’s different in 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”

15. Local Service Coordination Process • Track 2 – Family Team Model • Those individuals who have personal or professional relationship with the family • Formal and informal supports • Review of assessment summary • Safety/crisis plan • SC Plan created around PRIMARY need(s) and divides responsibilities among group

16. Local Service Coordination Process • Service Coordination Plan • Family identifies their long term vision • Family and team work together to identify and plan around immediate needs • Family and team clearly identify barriers and plan around them • Family and team incorporate strengths to help meet goals • Formal and informal supports incorporated • Progress is reviewed. Plan is updated as needed.

17. Goal of Service Coordination • Address issues that are impacting family stability • Maintain the child in the home when safely able to do so • Strengthen and empower the child and family unit • Connect with community resources and supports • Ensure that the formal and informal supports are working as a part of a team to help the family

18. The Jones Family – Case Example • Mom and Dad, Tommy and Ben • Tommy is 12 and was adopted by the family as a toddler. He is struggling in school and they are considering unruly charges, he refuses to go to counseling, and has been physical with 7 year old Ben. The case is referred by the school social worker.

19. Case Example • Family agrees to Family Team Model due to the level of crisis, risk of court involvement, potential placement in Attention Center, etc. • Assessment is completed. • Strengths – Enjoy camping together, Tommy and dad are artistic, marriage is strong • Informal supports – church family, sister-in-law, YMCA coach • Needs- Failing multiple classes at school, conflict with principal; transportation (dad’s job is at risk); finances are tight – increases parent stress; manage anger to increase success at school and decrease conflict at home

20. Case Example • Family Team Model • Mom, dad, Tommy, school social worker, teacher, juvenile court representative, church member, sister-in-law, YMCA coach come together for a meeting • Review assessment (strengths, needs, cultural issues) • Create safety plan • Identify needs and prioritize • Identify and plan around barriers • THIS PROCESS IS FACILITATED BY SERVICE COORDINATOR

21. Case Example • Two primary needs as determined by family= • School (failing, trouble with principal, mom called to school constantly, creates conflict with the family, hanging out with the “wrong crowd”) • Finances (car died, bills going unpaid, dad’s at risk of losing job)

22. Case Example • School – • School personnel indicates Tommy is having most difficulty in math and science and acts out the most during and after these two classes • Mom agrees that homework/grades/school functioning is typically what starts conflicts at home

23. Case Example • Service Coordination Plan - School • YMCA coach has a teammate who is studying math/science in college who may tutor Tommy • Church member volunteers to watch Ben so Tommy can be tutored at home with little distractions • School social worker agrees to create behavioral reward system to improve Tommy’s behavior and decrease Tommy’s negative interactions with principal • YMCA coach willing to have Tommy be statistician for H.S. soccer team to increase time with positive male role models/decrease time with the “wrong crowd” • Family and TCFCFC will share the cost of enrolling Tommy in an art class; Church member will provide transportation

24. Case Example • Service Coordination Plan- Finances • Parents agree to debt management/budgeting classes • Parents agree to Ways to Work to help dad purchase a vehicle • Sister-in-law agrees to work out transportation plan so dad can get to work • Parents agree to contact JFS regarding applying for PASS funding for families of adopted children

25. Case Example • How does this impact the local system? • There is a financial and emotional cost if Tommy receives charges in Juvenile Court • The risk of Tommy being placed in a specialized school decreases • There is a financial and emotional cost if Tommy’s is placed outside of the home • Cost to the school • Cost to the systems • Cost to Tommy and family

26. Case Example • The process has supported Dad remaining a member of the workforce • The process has involved informal supports to help the family meet some of their needs vs. creating a plan that relies on systems

27. Case Example • In between first and second family team meeting – • Service Coordinator • facilitates enrollment of Tommy in art class • Contacts school to obtain behavioral plan and shares with the family’s team • Confirms appointment time for Ways to Work and Budgeting meeting • Verifies progress has been made on tutoring plan

28. Case Example • Second Family Team Meeting within 10 business days • Review family plan • Meeting occurred for Ways to Work and Budgeting • School created behavior plan last week – can’t report on progress • Art class starts next week • Coach unable to find tutor for Tommy but he is helping at the YMCA • Family found to be eligible for PASS funding • Dad able to get to work through sister-in-law and co-workers

29. Case Example • In between second and third meetings • Service Coordinator • Verifies Tommy is attending art class • Determines progress with Ways to Work/Budgeting meeting • Works with school to determine progress with behavior plan and potential student tutor • Determines progress in involvement with Coach/YMCA

30. Case Example • Third Family Team Meeting • Family and team discuss where progress has been made and areas of continued concern • Mom is questioning potential FAS due to recent information regarding Tommy’s biological family • Service Coordinator updates Family Plan to include any additional issues, such as connection with Health Dept. to learn about FAS

31. Case Example As the level of risk and family crisis decreases, Family Team Meetings occur less and less frequently. Frequency may increase if an additional crisis occurs. Service Coordination ends when family can navigate the system, is not experiencing crisis, risk of removal is decreased, and supports are maintained or no longer needed.

32. Questions? • Contact info: • Tuscarawas County Family and Children First Council - 330-343-2286 Rindy Brace, Service Coordinator rindy@adamhtc.org