Comprehensive Care Planning with Youth & Families in RBS An overview & walk-through of a...

Comprehensive Care Planning with Youth & Families in RBS

An overview & walk-through of a Comprehensive Care Planning

Template

Martha Kaufman & Geri Wilson

8/31/2009 2RBS Coalition – MCKaufman & GWilson

Learning Objectives

• To understand the benefits of engaging families in

comprehensive care planning process.

• To learn how to develop a comprehensive care plan and track

progress throughout a family/youth’s enrollment in RBS.

• To practice using a case scenario to illustrate how a family’s

strengths, needs and cultural perspective informs the

priorities, interventions and outcomes of family/youth

enrolled in RBS.


A Functional Best Practice Framework

• Child, Youth & Family Voice & Choice• Practicality & Relevance• Outcomes Driven• Strengths-based, Needs-responsive• Right Time, Right Place, Right Kind of Care• Continuity & Portability• Coordinated & Comprehensive • Unified Efforts Across Systems & Locations• Adherence to Mandates


Service System Benefits

• Takes a step up to unify efforts vs. trying to alter multiple

long-standing documentation mandates

• Promotes coordination in planning & implementation – 1

family/1team/1plan

• Establishes a snap-shot of the big picture, without losing the

details (“I can finally tell what’s going on without slogging

through 50 pages!” MM, District Court Judge)

• Documentation that promotes adherence to best practices in

planning & implementation


Child/Youth & Family Benefits• “Finally, I feel like my daughter & our family have our own plan! It

belongs to us and not an agency, and helps us feel like we’re in charge of our lives.” (TD , parent)

• “I understand this – it has my own words in it.” (JS, youth)• “I can take this plan with me to help explain what we’re trying to do

to help our son. It has been hard to get some professionals to listen to me as a parent. Now we have a plan and a team that backs us up.” (DB & JB, parents)

• “What I like is that all the agencies that work with my kids now work together through one team and one plan. No more different plans that tell us different things. I used to worry about missing something and getting in trouble about it. I’ve got enough worries.” (ASR, parent)

• “I can show our plan to anyone I want to and it actually makes sense! It’s like our snapshot of what we’re working on and how we’re getting there, without all the mumbo jumbo.” (CJ, parent)

• “My husband and I can see a difference now that our team uses the Unified Plan to help us help our teenager. We’re all more on the same page and people are actually helping us work on OUR priorities.” (DP, LP, parents)


How is it different?

ChildWelfare

MentalHealth

Courts

JuvenileProbation

Separate Plans

& Orders

ChildWelfare

CommunitySupports

MentalHealth

Education

CommunitySupports

Education

RBS

RBS

JuvenileProbation

Courts

One Unified & CoordinatedComprehensive

Care Plan

One Unified & CoordinatedComprehensive

Care Plan


The Comprehensive Care Plan

• Helps the child/youth & family & their Care Team create one

overarching plan that coordinates efforts across agency &

organizational boundaries

• Does not replace, but integrates, agency-specific mandated

plans (CW, MH, etc) into one unified family-centered plan

• Uses a Life Domain framework to identify priorities,

strengths, needs & a plan of action to help provide help when,

where & how its needed through RBS

• Defines & coordinates the work of the Care Team


Using the CCPWho completes it?

The individuals who lead the

child/youth & family Care Team

take primary responsibility for

facilitating (& documenting) the

completion of the CCP:

• with full participation of the

child/youth & family and

• their key stakeholders/Care

Team members whose help is

needed by the child or youth &

family to help achieve their

desired outcomes

When?

• Upon enrollment in RBS as

part of the Care Team

development process

• At each Care Team meeting

• Whenever the CCP needs to

be reviewed and/or changed

consistent with evolving

goals, strengths, & needs of

the child or youth & family


How is it completed?Youth/Family, Stakeholders, & CT Leaders work together, building on

information shared in the Engagement Process: Strengths & Needs

Conversation, Assessment information (e.g., CANS Actionable Items,

CAFAS), & the history of care – what worked & what didn’t

• Initiate a Family-Centered exploration of the child/youth & family’s :

Stated Goals, Strengths & Skills, Unmet Needs & Driving Forces

• Identify the top 3-4 Life Domain priorities with the child/youth

& family (areas of their lives where actions will be focused), such as:

•A place to live•Getting along as a family•Taking care of physical health needs•Taking care of behavioral health needs•Participating in cultural & spiritual traditions

•Safety•Being part of the community•Doing well in school &/or work•Having friends•Having fun


How is it completed?• Within each priority LD, identify with the child/youth & family, Care

Team members:

• The key goals of the child/youth & family right now (as stated by the

family) based on their vision of how things can be different in the future

• Their strengths & skills

• Their unmet needs & driving forces behind disruptions that stand in the

way of achieving their goals

• Their hopes & desires about what they want to accomplish in RBS

• Action steps that are agreed upon (utilizing strengths/skills to meet needs

& achieve goals)

• What could go wrong, actions to address, & a Plan B (Crisis P&C Plan)

• (CT Facilitators) document all on the CCP, attach relevant agency-

specific plans

• Have all Care Team member sign, & provide them copies


Youth/Family referred for intervention

Comprehensive Assessment

Strengths & NeedsConversation

Assessment(CANS, CAFAS)

EngagementProcess

CM/Worker & Family

Explore/Select BestIntervention & Setting:

• Family-Based Support & Services (@ Home)• Family-Based Services (Out-of-Home)

• Residentially-Based Services• Locked Detention

RBS ComprehensivePlanning Process (within 30

days of enrollment)•Youth/Family

• Key Stakeholders• RBS Care Team Leader & Parent

Partner

Team DecisionMeeting

RBS EnrollmentMatch Youth/Family

Strengths & Needs with RBS Provider

Initiate the Care Team &Complete the CCP (cont’d)

Within the Youth/Family’s top 3-4 Life Domain Priorities:

•Youth/Family-Stated Goals•Strengths/Skills

•Unmet Needs/Driving Forces•Actions to be Taken

•Crisis Prev & Care Component(Reference & attach specific agency service plans/orders)

Initiate the Care Team &Complete the CCP

Review S& N Conversation, Assessment(s), History of Care (what

worked/what didn’t work, & Begin Family-Centered Exploration of

Youth/Family’s:

Goals ( their vision of how they want things to be different in their lives)

Strengths & skills Critical unmet needs that are the driving

forces behind disruptions that have occurred in their family relationships

Hopes & desires about what they want to accomplish through their RBS participation

The CCP defines & coordinates the work of

the Care Team

The CCP is reviewed at each Care Team meeting

(monthly/more often as needed) , using the CCP

Progress & Tracking Form

The Youth/Family & members of their Care Team change the CCP consistent

with their evolving goals, strengths & needs

The CCP Planning & Implementation Process


LIFE AREA/DOMAIN PRIORITY #1:

What are the Child/Youth & Family’s Stated * Goals?

Which Strengths & Skills will help meet these goals?

What unmetNeeds or Concerns** stand

in the way of meetingthese goals?

What Actions need to be takento meet these goals?

ACTION BY WHOM WHEN

Short Term: Child/Youth Family Child/Youth Family

Long Term (6-18 mo):

Transition (18 mo. +)

Note other documents that provide further detail (CWCP, IEP, etc.) here & attach. RELATED DOCUMENT(S):

COMMENTS:

* Goal = what it would look like to be doing okay in this domain of the child/youth & family's life, expressed from their perspective, in their words & reflecting their culture & preferences.

** This requires understanding the driving forces behind disruptions in relationships & the behaviors associated with those behaviors and/or events.


Crisis Prev & Care ComponentTips On Crisis Planning*

• Be sure to ask the child/youth & family what could go wrong during the implementation of the entire CCP. This is a first step in developing or revising the Crisis Prevention & Care component. The child or youth & family know best what can go wrong.

• Always build a crisis component that "triages" for different levels of intensity & severity of crisis events (prioritizing actions according to the seriousness of the condition or events). Small crises do not require the same response or reaction as more serious crises demand.

• Build the crisis component for a 24-hour response. Crises seldom occur when it is convenient.

• Always create a ‘Plan B’ in case the people who were supposed to provide backup or intervention are not available when the crisis occurs, etc.

• Always double check with the child or youth & family each time the crisis component is updated - Will it work?

* P

atri

cia

Mil

es (

2007

). C

risi

s P

lans

: Se

ttin

g th

e E

xpec

tati

on fo

r U

ncon

diti

onal

Car

e


Crisis Prev & Care Component*

CRISIS PREVENTION & CARE COMPONENT What crises are most likely to occur?

What actions will be taken to prevent/avoid the crisis?

What actions will be taken if the crisis occurs?

Who will take the actions?

What is PLAN B?

* Patricia Miles (2007). Crisis Plans: Setting the Expectation for Unconditional Care


Tracking Progress in the CCP

The CCP Progress & Tracking Form is a tool to help children or

youth & families participating in Residentially Based

Services (RBS), along with members of their care team (e.g.,

Family Support Team) assess how things are progressing,

what’s working & what’s not working in their

Comprehensive Care Plan (CCP).


CCP Progress & Tracking Form

Who completes it?

• The individuals responsible for facilitating the Care Team,

together with the child/youth & family & key stakeholders

whose help is needed to help them achieve their desired

goals.

When should it be used?

• At every Care Team meeting


How is it Completed?• The CT Facilitators review each Life Domain priority on the

CCP, related goals & action steps with the child or youth & family & other members of their Care Team to assess how well implementation of the CCP is going

• Through a consensus process, indicate on the Tracking Form how the Team would rate the progress in meeting each goal within the Life Domain priority, using the 1-10 scale, with 1 indicating ‘not working’ and 10 representing ‘total success’ . The care team should strive to agree upon a rating that is “good enough” to progress to a next goal, e.g., a “7”

• Always include a rating for the Crisis Care & Prevention Component

• Indicate the time frames that are being measured at the bottom of the Tracking Form chart, e.g., monthly


How is it Completed?• Once a few months of data are collected in terms of progress made, the

Care Team can create a graph to illustrate progress of goals over time

• The Comprehensive Care Plan & the Tracking Form are interrelated. When it is time to focus on new goals and/or to select new Life Domain Priorities (according to the results of the Tracking Form), utilize the CCP template to reflect changes as needed to respond to the child’s or youth’s & family’s changing strengths & needs as they progress toward their stated goals

• Indicate whether changes were made to the Comprehensive Care Plan as a result of the progress review & the date of the CCP that reflects these changes, if made

• Indicate the date, time & location of the next Care Team meeting

• Have every Care Team member sign the Tracking Form & provide them with copies


Life Domain Priority #1:

Youth/Family Goal:

Action Steps Taken:

Measure: Indicate below which number represents how well are things progressing to meet this Goal

Total success 10

9

8

Well enough 7

6

5

4

3

2

Not at all 1

Time Intervals: A B C D E F G H I

* John Franz, Getting from Hello to Help

CCP Progress & Tracking Grid*


Will & His FamilySue Jordan is 32 years old, married to Joe Jordan & the mother of three children, Britta (4), John (2), & Will (13). Will was removed from his parent’s care at age 4; after it was found out that he was being left alone for long periods of time while his parents went out with friends. Since that time, Will has been in multiple foster homes & residential treatment centers. Sue & Joe continue to struggle with the guilt of neglecting Will during their “wild years” & have hated to see him bouncing around in placements. At the same time their two young children both have disabilities, & while things are far from perfect, they are functioning as a family & doing okay.

Sue & Joe are both avid readers & take pride in the work they have done to understand how to meet Britta’s & John’s special needs. They have also tried to stay in Will’s life the best they can, remembering to send him birthday & holiday gifts that encourage his talent in drawing & support his interests in music & computers. Will treasures these gifts & makes a special place in his room everywhere he lives to keep them in view. He also carries a backpack with him that has the treasures he hopes to put out some day when he has his own room in his own house. He is trying not to give up on that dream, but wonders if there is still a place for him in his family.


Will & His FamilySue is finally pursuing one of her life dreams, going after a Med Tech degree at the local college. Joe, who had lived on the road playing for a minor league ball team (pursuing his dream to play in the major leagues), took a job in town a little over a year ago to help more with the kids so that Sue could attend classes. However, Joe was laid off three months ago. The family is now having a tough time making ends meet financially, because Joe has not been able to find another job.

Sue & Joe are just not sure that they can take care of Will, especially given their current financial situation & the behaviors Will has developed. They decided to try a couple of home visits last month to see how things went. They did not go well. Will refused to go along with his parents’ instructions & threw violent tantrums & Sue is worried that he might hurt Britta and John. She called the police twice because of the tantrums and an action in juvenile court is pending. Will came back to the residential facility feeling pretty angry & hopeless, telling staff that he just wants to be emancipated when he is 16, just like his older friend in the last foster home.

Last week, a staff member from the residential facility phoned Sue & Joe to let them know about a new option that might help their family, called RBS. It all sounded pretty complicated, but Sue & Joe agreed to meet with the staff to find out more.


Info from Strengths/Needs ChatWill • Has begun to make friends in the RTC• Has a strong connection with a former foster mother & they talk by phone• Just had a display of his drawings in the cafeteria during Art Week• Likes to write & is a quick learner, especially when he can use a computer• Hits first, asks questions later, but will talk it out if given a chance• Will take what he wants when frustrated• Was recently diagnosed with Bi-Polar Disorder & is worried about what that means• Is doing okay in small structured classSue• Is committed to finding a way to balance family & school• Is willing to keep trying to find a way to keep Will in the family• Is overwhelmed, gets frustrated • Has close friends in the neighborhood• Is involved in her Church• Wants to become more skilled using the computer for her school workJoe• Put his dream aside so Sue could pursue hers & is committed to finding another job • Is willing to consider options that could help Will be with the family again• Has friends on the neighborhood soft ball team• Is worried about money but doesn’t feel like he can show it• Has a temper, but has learned to step back before he reacts


Findings from the CANS

Strengths that can be further developed:

• Interpersonal

• Educational

• Talent/Interests

Strengths that must be built:• Family

• Relationship/Permanence

• Vocational

• Well-being


Findings from the CANSMild degree of need or watchful waiting to see if need develops:

• Family Functioning

• School Achievement

• Depression/Anxiety

• Adjustment to Trauma

• Temporal Consistency of Mental Health Problems

• Abuse History

• Social Behavior

• Seriousness of Criminal Behavior

• Urgency of Care Management

• Supervision

• Organization


Findings from the CANS

Moderate need and need for action:

• Permanency• Psychotic Symptoms• Attention Deficit/Impulse Control• Anger Control• Oppositional Behavior• Violence• Monitoring• Treatment Intensity• Service Permanence• Family Involvement w/Care• Family Knowledge• Family Resources


Will & Family’s Care TeamName & Signature Relationship/Agency/Organization Phone Email Will Jordan Will Jordan

Myself!!WillCoLater@ hotmail.com

Sue Jordan

Sue Jordan Will’s motherSJ [email protected]

Joe Jordan Joe Jordan Will’s father [email protected] Bennet Dan Bennet Care Team Coordinator

DBennet@RBSconnect. com

Cheryl GatesCheryl Gates Parent Partner

[email protected]

Abby Lowe

Abby Lowe RBS Program Team/Therapist [email protected]

Sally Holt

Sally Holt Friend & [email protected]

Henry LamontHenry Lamont Teacher & coach

[email protected]

Edith MannEdith Mann

Will’s former Foster Parent

[email protected]

Susan Houston Susan Houston Juvenile Court Counselor

[email protected]

Jim RothJim Roth

Child Welfare Case Worker [email protected]


LIFE AREA/DOMAIN PRIORITY #1: A place to live & get along with family (Residence, Family, Permanence)

What are the child/youth & family’s stated

Goals?


What unmetNeeds or Concerns stand



ACTION BY WHOM WHEN

Short Term: Child/Youth Family Child/Youth Family

To feel like it’s really possible to fit in with my family & not blow it by getting upset (W)

When upset will talk it out if given a chance

Is willing to consider options that could help Will be with the family again

Driving forces – loneliness, fear of never finding a family to love & be loved by, fear of abandonment.. Need for hope.

Assessment & support viafamily visits in RBS facility

Phone support by W’s former FP

•Support Will in writing a self-portrait & about his dreams for the future to share w/Family

Dan J/lead, w/RBS site team & Cheryl G.

Edith M.

Abby H, Jim R(See attached CWCP for further detail)

Saturday 9/12 & 9/26

Weekly, beginning 9/3

•Beginning 9/10

Get to know W again as a person & let him know we love him (S&J)

Enjoys using computer, wants to be close to his family

Driving forces - fear about ability to keep the family together safely;Guilt about abandoning W;Overwhelmed about parenting. Need for hope.

Have enough money to keep our home & take care of our children & meet their special needs(S & J)

Commitment to finding a way to balance family and school (S);Follow all leads on job possibilities (J);Continue reading about best ways to help our children (J&S)

Joe’s concern that he won’t be able to support his family; Sue’s need to balance home, children & school;Concern about W’s diagnosis & what it means he needs (S&J)

Educational sessions w/family about W’s dxFacilitate connection to new community Recession-Proof Financial Support program

Dan J/leadw/RBS site team

Cheryl G.

9/12

9/22


LIFE AREA/DOMAIN PRIORITY #1: A place to live & get along with family (Residence, Family, Permanence)

What are the child/youth & family’s stated

Goals?


What unmetNeeds or Concerns stand



ACTION BY WHOM WHEN

Long Term (6-12 mo) Child/Youth Family Child/Youth Family

To feel confident as parents of a teenager (S&J)

Hx of reaching out to learn how to help the children

More practical information about how to do this everyday

Facilitate connection to Parents of Teens community group

Dan J & Cheryl G.

By2/1/10

To feel like I can have my own room in my own house & stop worrying about moving all the time (W)

Keeps gifts & cards from family to go into his room;Loves to draw

Confidence that his room is there for him and is a part of him & a part of the familyhome

Support Will in creating new drawings for his roomRedecorate Will’s room

Sue, Joe,

Sally

Will, Sue, Joe, Sally

By 2/1/10

Beginning 2/15/09

Transition (18 + mo)Staying together & getting along as a family (W, S, J)

Note other documents that provide further detail (CWCP, IEP, etc.) here & attach. RELATED DOCUMENT(S): Child Welfare Case Plan


Tracking Progress

Goal: Get to know W again as a person & let him know we love him (S&J)

Action Steps Taken: Assessment & support via family visits in RBS facility; Phone support by W’s former FP

Measure: Indicate below which number represents how well are things progressing to meet this Goal Total success 10 9 8 Well enough 7 . 6 5 …. 4 3 2 Not at all 1

Time Intervals:

1 mo 2 mo 3 mo 4 mo


Testing the CCP in Sacramento

• Creates a "standardized" centerpiece for a coordinated care planning approach for RBS providers and county case managers

• Provides a solid foundation for family focused, strength-based, individualized care plan development

• Ensures the case planning process is inclusive, overarching and coordinates the efforts and requirements of all key stakeholders

• Serves as a great communication tool and provides the opportunity for the Care Team to create a shared vision for care and outcomes

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