Collaborative Systems of Care: the Role of Schools, Parents, and other Service Providers Thursday Ma

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Collaborative Systems of Care the Role of
Schools, Parents, and other Service Providers
Thursday March 17, 2005

• Faye Wilson, Special Education Teacher
• Weyauwega Middle School
• Tina Swinford, Parent Advocate
• Wisconsin Family Ties
• Howard Harrington
• Waupaca County Coordinated Services Team
  Initiative
• Dan Naylor
• Bureau of Mental Health and Substance Abuse
  Services

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Systems of Care

• A wide range of related services and supports
  organized to work together to provide care
• Help individuals get the care they need in or
  near their community
• Implement a tailored set of services and supports
  to address all family needs

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The Importance of Partnership

• No single agency has the staff or resources to
  serve all individuals with complex needs.
  Drawing on the expertise and energy of many
  agencies and individuals working together can
  increase resources.
• Successfully meeting the needs of children with
  complex needs, their families, and team partners,
  requires a close collaborative relationship with
  the participant. Families must be actively
  involved in the planning, implementation, and
  evaluation of services.

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Principles of Collaborative Systems of Care

• Family-centered approach
• Consumer involvement throughout the process
• Building resources on natural and community
  supports
• Strength-based approach
• Providing unconditional care
• Collaborating across systems
• Using a team approach across agencies
• Being gender/age/and culturally responsive
• Ensure safety
• Promoting self-sufficiency
• Focus on education and employment where
  appropriate
• A belief in growth, learning and recovery
• Being oriented to outcomes

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Collaboration with Families

• Voice The child and parent are listened to and
  heard in all phases of the planning process
• Access The child and parent have valid options.
  No services are withheld for categorical reasons.
• Ownership The child and parent agree with and
  commit to any plan concerning them.

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The Changing Role of Parents

• Realization by service providers that parents
  (and natural supports) are there for the long
  haul as their child moves through the system
• Parents as experts of their child and family
• Parents as team partners
• Parents as service providers
• Parents as advocates
• Parents as service coordinator

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Entering the Coordinated Services Team Process

• Single point of entry access to the whole system
  of care through one person
• Remove obstacles challenging concepts of
  eligibility
• Shorten time underway in 30 days

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Qualifications for Family Team Involvement

• To qualify for team involvement, individuals
  should
• Have a role in the lives of the child family
• Be supportive of the child family
• Be supported for membership by the parent
• Be committed to participate in the process
  including regular team meeting attendance
• Participate in discussions
• Be involved in the Plan of Care

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Potential Members of Teams
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Levels of Team Involvement

• Assessment, Planning, and Crisis Response
  Planning
• Teams meet every 1 2 weeks for 45 minutes to 1
  hour
• Phase may last approximately 2 3 months
• Plan Implementation Monitoring
• Teams meet as often as necessary, typically every
  3 5 weeks
• Phase may last approximately 6 12 months
• Transition Closure
• Teams may meet every 2 3 months while
  transitioning out of the formal team process

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Summary of Strengths Needs Assessment

• Living situations
• Basic needs and financial status
• Child family situation
• Mental health
• Social interaction
• Access to community resources
• Cultural involvement
• Spiritual status
• Educational/vocational status
• Legal involvement
• Medical status
• AODA status
• Crisis response

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Plan of Care Development

• The service coordinator schedules meetings with
  the family team to develop the plan
• The team reviews process principles, and
  identifies the strengths of the individual and
  team member.
• The team reviews each domain, identifying
  strengths, needs, and the childs current level
  of functioning.
• The team prioritizes the needs
• The team develops the Plan of Care to include
• The childs present level of functioning
• The goals, objectives and activities
• Who will be involved
• How services will be paid for
• How outcomes will be evaluated

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Crisis Response Plan Development
A crisis occurs when adults dont know what to
do. Carl Shick

• Expect that a child with multiple needs living in
  the community will experience crisis.
• Consider the most challenging act(s) that could
  happen
• Review historical strength-based information
  regarding strategies that have worked
• Pre-plan interventions with people and/or
  agencies who may be involved in the safety issue
• Develop a protocol of who will be notified, in
  what time frame, including responsibilities and
  communication procedures
• Establish a blame free time in which team
  members cannot fault each other for the crisis
• Develop a process for evaluating the crisis
  response plans use within two weeks of the event.

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Transition

• The intent of the team is not to solve every
  problem that the family or the providers have,
  rather to develop skills, gain knowledge and
  identify and access resources necessary to meet
  the needs.
• Once this process is working and doesnt
  necessitate team support, the formal team process
  should end.
• This doesnt mean that services arent necessary
  or that supports arent needed. It simply means
  the family has voice, access and ownership.

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Personal Benefits of having a Team for Our Family

• All service providers on same page
• Whole team is aware of important information
  regarding the family for example, what works
  what doesnt
• Having a Safety Plan in place for home and school
• Not One size fits all Our team centered
  around our strengths and needs
• All team members are treated as equals, yet each
  brings their own strengths knowledge
• More is accomplished as a team than working
  individually with each service provider
• The team supports the whole family, not just one
  child or person

Created by Tina Swinford Waupaca County Family
Advocate, Wisconsin Family Ties
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Personal Challenges with our Family Team

• Changing caseworkers often and trying to get them
  up to speed
• Important service providers not fully
  understanding/not knowing about the team process
• Having the key child in the meeting our
  daughter is a very important member of our team,
  but experiences anxiety overwhelm when in the
  team setting

Created by Tina Swinford Waupaca County Family
Advocate, Wisconsin Family Ties
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Where I Am Today

• I am now a family advocate for Wisconsin Family
  Ties, a statewide, non-profit organization
• I was originally hired as an advocate for Waupaca
  County, but now advocate for families in other
  counties as well
• I advocate on behalf of families in many ways
• Encourage support families in their
  communication with their team members
• A voice of encouragement
• A person they can call when they need someone to
  listen
• Support group (Embrace) once/month
• Ensuring family feels included in decisions
  discussions
• Being the bridge between families and service
  providers
• I am an active member of the Integrated Services
  Coordinating Committee
• Speaker/presenter for Integrated Services Project
  trainings I tell my personal story including
  the benefits and challenges we have with our team

Created by Tina Swinford Waupaca County Family
Advocate, Wisconsin Family Ties
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A Checklist for Partnering with Parents

• Can I put myself in the parents shoes?
• Do I wee the whole child?
• Do I value the parents as experts on their kids?
• Do I believe we are equals?
• Do I listen, communicating that I respect and
  value their insights?
• Do I always answer parents questions?
• Do I speak in plain language, avoiding jargon?
• Do I strive for common understanding?
• Do I schedule according to family needs?
• Do I follow through on my commitments?

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Effective Listening

• Check your understanding
• Paraphrase
• Reflect feelings
• Learn when to be quiet
• Take the time
• Dont rush to reply
• Be present

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Building Trust With Families interviews with
family members

• Listen with true concern without judging
• Dont rush decision-making
• Two-way conversation get to know each other
• Be honest
• Dont pretend to understand if you dont
• Treat parents as equals acknowledge they know
  their child best
• Step into their world work with families
  where theyre at
• If you dont know the answer, say you dont
• Clear Expectations

Adapted from interviews between Wisconsin Family
Ties advocate, Tina Swinford and parents involved
in the CST/ISP process6/04
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Components of Effective Parent-Provider
Collaboration

• Caring, non-blaming attitude toward the family
• Recognition of the family as the key resource
• Recognition of family limits and responsibilities
• Shared power and responsibility
• Joint decisions and solutions
• Support and understanding
• Practical assistance
• Open and clear information sharing
• Readiness to alter services based on feedback

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Parents Positive Response to Service Providers

• They are natural, act real, talk openly.
• They share experiences.
• They are positive and willing to listen.
• When we work as a team.
• When we become advocates together for services.
• They recognize parents expertise and believe
  it.
• Families as Allies Project 1989

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Faye Wilson, Special Education Teacher Weyauwega
Middle School
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Why Coordinated Service Teams?

• 4 heads better than one
• Multiple expertise
• Meeting during non-crisis times, as well as,
  crisis times

Faye Wilson, Special Education Teacher Weyauwega
Middle School
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Staff

• Awareness of the whole child
• Ownership of goals implementation
• Willingness to accept setbacks

Faye Wilson, Special Education Teacher Weyauwega
Middle School
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Scheduling

• Prep Periods Police Scheduling
• After School Case Worker Scheduling
• Team Times Advocate Scheduling

Faye Wilson, Special Education Teacher Weyauwega
Middle School
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Administrative Support

• Attendance at Meetings
• Scheduling
• Personnel Ideas

Faye Wilson, Special Education Teacher Weyauwega
Middle School
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Benefits

• Communication
• Team Effort
• Trust

Faye Wilson, Special Education Teacher Weyauwega
Middle School
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Concentrated Focus

• Reactive
• Proactive

Faye Wilson, Special Education Teacher Weyauwega
Middle School
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Sample School Crisis Response Plan

• Past behaviors/situations considered crises or
  safety concerns Usually starts with refusal to
  comply with a request or to follow routine. Can
  escalate quickly to swearing, physical
  aggressiveness, destruction of property, and
  self-harm.
• Mental Health Diagnoses ADD Intermittent
  Explosive Disorder Mild Developmental Disability
• Rx (include name of doctor prescribing Lithobid,
  Trazodone, Trileptol, Risperdal Dr. Bob
•  
• Progressive list of interventions to respond to a
  Crisis/Safety situation
•   If at any time, Billys behavior escalates to
  the point of harming himself, someone else, or
  destroying property, go directly to Step 5
•  Praise Billy for following requests and
  routines. Some reinforcers include verbal
  praise, tokens, star for his chart, physical
  contact (e.g. hugs), and edible treats (cottage
  cheese, cereal, cookies, etc.)
• If Billy refuses to comply with a request or
  routine, he usually physically distances himself
  from others (e.g. pushing his chair away from the
  table, crossing his arms and putting his head
  down). Allow Billy a 5-minute refusal. Billy
  knows that he has this five minutes to regroup
  and come back to join the class.
• If Billys behavior escalates to the point of
  swearing or physical aggressiveness, he will be
  escorted to the time out room and given up to 30
  minutes to deescalate and rejoin the class.

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• 4. If Billy is not able to re-join the
  class after 30 minutes, he will be removed from
  school.
• The following individuals can be contacted in
  this situation
•          Jo
  Susan Smith (parents) 555-2503
•          Don
  Jones (family advocate) 555-5120
•          Marsha
  Miller (mentor) 555-5026
• If the above individuals are not available, and
  Billy has not committed a crime (e.g. property
  destruction, harming someone) he will receive 11
  supervision by school staff (if possible) until
  someone can be reached to come get Billy. If 11
  supervision is not possible, move on to step 5
• 5. Contact law enforcement (555-3321) to
  transport Billy to the Work Release Center.
• Once there, the officer should contact DHS intake
  (555-3303). A social worker or on-call staff
  will come over as soon as possible. Note to
  responding officer Billy has a cognitive
  disability it is important to be firm with him,
  but to also use very simplistic language dont
  try and reason with him
• Social worker/on-call staff If Billy is o.k. to
  go home, try and contact one of the individuals
  listed under 4A to come and get Billy. If no one
  can be reached by 330 OR if it is determined
  that Billy should not go home, the following
  options should be considered
•          Village of Learning daycare center
  (to be used only for a few hours and if Billy is
  not a danger to
• self or others)
•          County receiving home (see Child
  Family Unit supervisor - Beth)
• Hospitalization at St. Elizabeths (if
  hospitalization is needed)
• This Safety Plan has been distributed to DHS
  Crisis On-Call Unit and Child Family Unit,
  Sheriffs Department, Police Department,
  Riverview School, Jo Susan Smith, Integrated
  Services team members

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Role of Service Coordinator

• Assure Team Completes the Assessment and Plan of
  Care
• Central Team Contact
• Ensure the Plan of Care is Monitored
• Ensure Reassessment and Plan of Care Updates
• Share Outcomes

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Key Team Meeting Responsibilities of the Service
Coordinator

• Open the meeting, welcome team members
• Review and add to the agenda
• Set meeting time limit
• Prioritize agenda items if necessary
• Ensure notes are taken and plan for distribution
• Keep team focused, moving through the agenda
• Keep track of time
• Facilitate discussions and conflict resolution
• Ensure member participation
• Assist team in decision-making
• Set agenda, time, and place of next meeting

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Promoting Consensus Building
Adapted from The Team Handbook Sholtes, 1996
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Barriers to Collaboration

• I dont have signed releases to share or obtain
  information
• Theres no money available to pay for services
  for needs identified in the Plan
• If I make an exception for one participant, it
  wouldnt be fair for the others
• My workload is too large I dont have time!
• My boss is pressuring me to stay in the office
  increase face-to-face time
• Ive never been involved in Wraparound and dont
  know anything about it
• Ive been involved before it wasnt beneficial
• I must maintain professional boundaries with
  clients
• I cant stand working with that person/agency!

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Principles for Conflict Management

• Encourage equal participation we are in this
  together
• Actively listen you are important and valued
• Separate fact from opinion challenge categorical
  statements
• Separate people from the problem use the board
• Focus on the big picture reaffirm goals,
  principles, values
• Build consensus

Adapted from Conflict Management, Hendricks, 1989
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Evaluation

• Develop Plan of Care
• Include Measurable, Attainable Goals, and Who
  will do What by When
• Use Plan of Care to Monitor Progress
• Team Effectiveness Survey
• Provider Satisfaction Survey
• Family Closure Survey

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Sampling of Outcomes/Benefits

• Majority of children remain in their home, school
  community
• Family advocacy informal support services are
  available
• Communication, collaboration, and coordination
  have improved in responding to the needs of other
  children and families
• Other funding sources have been leveraged
• Child abuse and neglect prevention
• Family preservation and support
• Targeted case management intensive in-home
  therapy
• Other grant and foundation funds requiring
  collaboration
• Funds have shifted to lesser cost
  alternatives/pooling of funds
• Several beneficial workshops/trainings have been
  provided
• Less duplication of services, workload is shared
• A shift toward outcome-based activities has
  occurred
• Participant involvement in development,
  implementation, and evaluation of activities has
  resulted in more community ownership of process

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Client Alumni Involvement

• Informal Resource
• Advocacy
• Support Groups
• Coordinating Committee Membership
• Screening Committee Membership

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Maintaining Successful Partnerships with Schools

• Involve families as decision-makers in all
  systems
• Find common ground
• Work toward state funding policies that reward
  collaborative planning
• Understand legal and political realities of other
  systems
• Be wiling to contribute funds and services rather
  than hold back
• Respect one another even when you strongly
  disagree
• We all must contribute or none of us will succeed
• Be willing to put in the time necessary to make
  it work
• Care deeply and respect fully

Adapted from Jonathan C. McIntire, Ph. D.
Administrator of Special Education, Vermont
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Advantages of the Integrated Services Process
from the Perspective of a Special Education
Teacher

• Communication is quick and clear
• Genuine commitment to reaching goals
• Support of child, family, E.D. teacher, and all
  involved
• Positive, no-fail approach
• Consistent accountability
• Informal settings at convenient times
• Pro-active planning
• Celebrate the victories, regardless how small
• Appreciation Good old-fashioned pats on the
  back

No longer does the E.D. Teacher, parent, or
anyone else have to feel like theyre the Wizard
of Oz and provide all of the solutions to all
the problems. Jeff Hutchinson, Special
Education Teacher Wild Rose High School
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Developing a Collaborative System of Care The
System Element

• Determine who should be involved in interagency
  planning management
• Determine what opportunities barriers exist to
  the development of a collaborative system of care
• Determine mission principles to be outlined in
  an Interagency Agreement
• Determine which agency or agencies will be
  providing administrative coordination
• Determine how collaborative funding staff will
  be provided
• Determine how the client voice will be included
  in all interagency planning operations

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Developing a Collaborative System of Care The
Program Element

• If necessary, agencies will make structure
  changes allowing for active participation.
  Internal system issues will be addressed
  including recruitment, training, supervision,
  service documentation, and billing
• Determine how client voice will be incorporated
  in planning operations
• Clarify communication procedures with partners
  clients
• Clarify a conflict management process
• Determine target population, program capacity,
  staffing, and supervision needs

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Developing a Collaborative System of Care The
Practice Element

• Staff are trained in utilizing a strength-based,
  multi-domain practice model
• Implementation is monitored and supported with
  ongoing coaching provided
• A quality assurance process is established to
  provide feedback for clients and staff

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Key Components of a Collaborative System of Care

• Clients involved as full partners at every level
  of activity
• Coordinating Committee agrees upon values
  principles as articulated in an Interagency
  Agreement
• Collaborative consumer teams create implement
  individualized support and service plans of care
• Sufficient collaborative funding is available to
  meet the financial needs identified in the Plan
  of Care
• Advocacy services are provided
• Ongoing collaborative interaction training are
  provided to all participants
• Functional goals are monitored measured,
  emphasizing participant satisfaction

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A Summary of Steps forDeveloping a Collaborative
System of Care

• Identify partners develop polices
• Determine target population
• Determine process for referral enrollment
• Identify and train service coordinators
• Implement the team process
• Establish monitoring evaluation processes
• Ensure sufficient collaborative funding
• Develop a collaborative plan for sustainability

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