Service Coordination Plan

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Service Coordination Plan

Tuscarawas County Family & Children First Council Service Coordination Mechanism was established pursuant to the Ohio Revised Code, sec. 121.37 with the approval of the Department of Job and Family Services, Department of Developmental Disability, ADAMHS Board, Tuscarawas County Health Department, Tuscarawas County Juvenile Court, New Philadelphia City Schools, Family and Children First Council and the Early Childhood Coordinating Committee to ensure that multi-need children and their families receive coordinated care and local supports. This ongoing effort focuses on strengthening families to decrease the potential of out-of-home placements, decrease the potential of court involvement, increase a child’s school success, and stabilize home stressors that may create unnecessary burden on families. Service coordination builds upon the strengths of the existing community services, incorporates formal and informal supports and strategizes to address unmet needs. The result of this wraparound approach will be more successful and stable children and families in Tuscarawas County.

For the service coordination process to be effective the following eight points have been considered in the creation of this mechanism:

  1. Are the services delivered using a family-centered approach?
  2. Are families fully involved in decision-making?
  3. Are the families’ cultural, racial, and ethnic differences considered in the provision of services?
  4. Are the families receiving the benefit of a wraparound approach to services and supports?
  5. Is the system considering specialized treatment options and evidence based practices in the delivery of services?
  6. Is there awareness of duplicative services or efforts?
  7. How does existing or potential funding impact the service coordination process?
  8. Do the outcomes of the service coordination process support its effectiveness?

The Tuscarawas County Family and Children First Service Coordination Mechanism strives to address these eight points through two service coordination tracks.  Regardless of the service coordination track utilized by the family, the process will focus on strength based and culturally sensitive discussions utilizing family voice and family choice.   A feedback loop between the families involved in the process, the service coordinator and the Service Coordination Committee will provide data regarding effectiveness of the model as well as opportunities for growth in the mechanism.

Purpose

The purpose of the Tuscarawas County Family and Children First Service Coordination Mechanism (SCM) is to apply the knowledge and experience of families and professionals toward the development of a family-centered and cost-effective plan of action for families and children who are involved with one or more service providers.  Information is shared and coordinated between agencies while protecting and assuring the confidentiality of the child and family.

The Tuscarawas County SCM targets children and adolescents age 0-21 who are multi-need or have multi-system involvement and struggle to maintain a level of stability. These individuals are often at risk of placement disruption and have the potential to move to a more restrictive level of care. A primary focus of service coordination is also those children at risk of court involvement due to unruly behaviors. Maintaining the children in the community when appropriate and safe as well as focusing on the least restrictive environment to stabilize a child is a priority of the Tuscarawas County Family and Children First Council.

Increasing Awareness of the County Service Coordination Mechanism

For service coordination to be successful, it is necessary to increase understanding and buy-in from those agencies and individuals not presently fully engaged in the process.  Increasing the engagement Tuscarawas County schools and Tuscarawas County Juvenile Court, and the Tuscarawas County Prosecutor’s office is a priority.  Additionally, making information accessible to other providers not involved in Council as well as the community at large will increase awareness and potential referrals to the service coordination process. To this end, a presentation will be developed and shared with providers and schools to increase commitment to the service coordination process and will be updated on an ongoing basis.  The presentation will be shared with Parent-Teacher Organizations and other parent groups and community organizations as appropriate.  Information will also be included in Council membership packets for all new Council members. The mechanism will appear on the Tuscarawas County FCFC website and brochures explaining the process will be placed in waiting areas of doctor’s offices, at libraries, at churches, etc.

Service Coordination Process:

The Tuscarawas County Family and Children First Council will implement a two pronged approach to service coordination.  Children and families that present with high needs will be encouraged to consider a Family Team model described below.  Council is aware that not every family referred to service coordination will have needs that warrant an intensive Family Team model. Families that identify less intensive needs, do not have a child at imminent risk of out-of-home placement or returning from out-of-home placement, or are not at risk of court involvement may choose a less intensive track of service coordination, the Family Stability model.   The service coordinator will determine a family’s needs and willingness to participate in the different options of service coordination during the initial phone call. Assessments are completed on all cases regardless of the track appropriate for that child and family.  It is worth noting that while the service coordinator may recommend one approach based on the referral, discussion with the family, and completion of the assessment, the coordination track is ultimately the family’s choice.

Council is also aware that not every family referred to the service coordination process will have needs that warrant service coordination.  The Service Coordinator will make that decision in conjunction with the family and provide the family with appropriate feedback, referrals, resources, and services to meet that family’s needs.  The family will be made aware that they are welcome to reconsider involvement in service coordination should that level of involvement become appropriate.

Referrals:

The initial gateway into the service coordination process is the referral.  Referrals will be accepted from existing service providers, including juvenile court, family supports, professionals in the community, and the family. The individual will have the option to complete either a paper or computer-based referral form. This form will keep confidential information to a minimum as much of it will be gathered during an initial phone contact or face to face meeting with the family and during the assessment process. Any provider completing a referral will obtain a release of information from the family prior to completing the form and will provide the family with a basic description of the service coordination process. A more thorough description will be provided by the service coordinator during the initial phone call or meeting.  Additionally, the family can contact the service coordinator and complete the referral via phone if that is most convenient.  The service coordinator will contact the family or send a letter if the family does not have a phone within three business days of receiving the referral to discuss the referral, review the service coordination process, and schedule the assessment meeting if the family is interested in participating.  During this contact, the initial family team meeting will also be scheduled if appropriate.

  • Components of the referral form include:
    • Date of receipt of the referral
    • Contact information for the person being referred
    • A brief description of the problems being experienced
    • Contact information for the person referring
    • Council response to the referral or outcome of the referral

Assessments:

Families will be contacted by the service coordinator within three business days from the receipt of the referral.  All families that agree to the service coordination process will complete a strengths, needs, cultural discovery assessment.  When possible and appropriate, it is highly recommended that the child be invited/encouraged to participate in the service coordination process beginning with the assessment. The assessment will focus on the strengths, needs, and cultural issues specific to the child and family and will occur in the family’s home or at an agreed upon location within five business days from the date of phone contact by the service coordinator. During this meeting, the service coordinator will again review the service coordination process, the two tracks of service coordination, confidentiality, and complete the assessment packet with the family and family supports should the family choose to involve them. The date and time of the subsequent meeting will be confirmed if it is determined this is an appropriate referral to the Family Team model. Upon obtaining the releases of information, the service coordinator will contact other individuals appropriate to attend the family team meeting and notify them via email and/or phone of the initial meeting. The child’s existing service providers, including a representative from the child’s school district, will be notified and invited to attend this meeting as well as formal and informal supports. This meeting will occur within ten business days of the date of the assessment in order to allow providers to adjust schedules to attend the meeting. The service coordinator will also review the family’s option to invite a parent advocate to participate in the process.  Upon completion of the assessment, the service coordinator will review the content with the family prior to presenting it at a Family Team meeting.

This assessment packet will include:

  • Releases of information for all service providers and family supports for each child involved in the service coordination process.
  • A crisis and safety plan or the service coordinator will obtain a copy of an existing crisis/safety plan created by the family in conjunction with a service provider to help the family maintain stability as the process of service coordination begins.  For children that are in emergency placement and don’t have prior involvement in the service coordination process, a crisis and safety plan will be developed in preparation for the children’s return home or to a less restrictive level of care
  • A strengths, needs and cultural discovery assessment
  • A document describing privacy and confidentiality expectations of information shared during the family team meetings

Track 1 – Family Stability – designed for families with less intensive needs

The Family Stability track focuses on service coordination orchestrated with the family and the service coordinator as the members of the team. Upon completion of the assessment, the service coordinator will continue work with the family with written and/or verbal feedback from the service providers to create a service coordination plan if appropriate.  Information from the service providers will be included in the service coordination plan. The family and service coordinator will sign the plan indicating understanding that each had a role in creating it and all are responsible for the outcome of the plan.  The service coordinator will have ongoing collaborations with the family to review responsibilities related to the plan as well as monitor the progress of the plan. The family can at any time request a meeting by contacting the service coordinator to review the service coordination plan and discuss progress.

At any time the need arises, the family can transition to the Family Team Model.The case will continue with at least monthly phone or face-to-face contact to monitor stability and review progress toward the plan.  The type of contact will be based on family choice.

Closure of a service coordination case will be based on a few factors: when the team, including the family, believes stability has been maintained and risk has decreased, the family indicates a desire either directly or indirectly (e.g. not returning phone calls, or attending meetings) to end the service coordination process, the family does not participate in the service coordination plan, or the family has access to the necessary resources to maintain stability.

Track 2 – Family Team – designed for families with more intensive needs

The initial family team meeting will occur within ten business days of the completion of the initial assessment. The service coordinator will begin the Family Team meeting by reviewing the service coordination process and obtaining signatures on the Confidentiality Expectations Form from all individuals present.  These meetings will be organized by the service coordinator via telephone contact or correspondence and should be comprised of those individuals who have a personal or professional relationship with the family and who the family approves as participants. The family is encouraged to invite either formal or informal supports to participate in the process. If an agency has a legally mandated requirement to provide a specific service that agency will be invited to attend. The service coordinator will share the results of the assessment with providers at the initial meeting following prior family review and approval.  The information will include a discussion of the family strengths, needs, and cultural issues to be considered.  The family team will review the safety/crisis plan created or obtained and review its effectiveness to meet the family’s needs.  Those present at the family team meeting will address the primary needs, identifying specifically the three biggest concerns at maximum that the family determines are threatening stability. A service coordination plan will be created around these specific concerns with other less urgent concerns to be addressed more in-depth at a subsequent meeting. The service coordination plan will focus on implementation in the least restrictive setting and appropriate level of service intensity.  The plan will identify and organize providers, services, and responsibilities. Timelines will be established and progress will be reviewed at subsequent family team meetings. All present will sign indicating their participation in the creation of the service coordination plan.   At the end of the family team meeting, the family team will decide on a meeting location for the next meeting. The second family team meeting will occur within 10 business days or as agreed upon by the family and the family team.  An email or phone notification will be sent to those present or additional team members as appropriate as a reminder for this and any subsequent meeting.

During the second meeting, the service coordination plan will be reviewed and progress toward the goals and responsibilities identified during the prior meeting will be discussed.  Any additional issues will be identified and incorporated into the service coordination plan as appropriate. A third meeting will occur within 10 business days or as agreed up on by the family and the family team with the same agenda. Subsequent meetings will be scheduled based on the family team’s needs and progress.

Additionally, while the service coordinator will most likely fill this role, the family has the right to choose an individual other than the service coordinator to track the progress of the plan, schedule reviews, and facilitate the family team meeting process.

While time frames are identified for family team meetings, the family can at any time request a family team meeting by contacting either the service coordinator or an individual designed by the family the lead the process to review the service coordination plan and discuss progress.

Service Coordination Plan

Family needs, strengths, and cultural issues will be identified during the assessment process and carried through the service coordination plan. The family will begin by identifying their overall vision for their child/family as well as more immediate needs. It is vital for the family to identify those needs that will have the most significant impact on child and family functioning and how their strengths can impact these needs.  The needs that most threaten stability and child/family functioning will be determined as the priorities on the service coordination plan. The format for the service coordination plan is used regardless of the track chosen by the family.

It is expected that, at times, there will be items on the Service Coordination Plan that will require funding.  The Service Coordinator will be responsible for being aware of the funding opportunities as well as the balance of any financial resources available to support service coordination families.  Examples of these types of funding are Family Centered Services and Supports, pooled funding resulting from Council member contributions, grants, and financial resources of local civic clubs whose mission relates to Council’s mission. The Service Coordinator, in conjunction with the Family Team when applicable, will prioritize which supports, services, resources, etc. are most important to family stability based on available funding.  These expenditures will be reviewed at the monthly Service Review Committee.

The Tuscarawas County Service Coordination Plan will include:

  • Responsibilities clearly identified for all involved parties. The parties can be state, county and local, public and private agencies and informal supports.
  • Who will coordinate services. Families will approve the person who will coordinate services. This person will make sure that the individual service coordination plan is implemented and the family continues to get the planned services. In many cases, this may be the service coordinator.
  • Consideration that services will be delivered in the least restrictive environment.
  • A timeline for when an individual service coordination plan is reviewed and progress is expected to be made. If a family is choosing the Family Team Model, the plan must state when the family and agencies will meet and talk about if the plan is working or needs to be changed. This is done in a less formal manner in the Family Stability track.
  • A plan regarding how to address gaps in services that impact the child and family well-being. These gaps in services will be shared with the Service Coordination Committee (see below) and the full Council

Service Coordination Committee

In addition to the family-specific focus of service coordination, Tuscarawas County Family and Children First Council will implement a Service Coordination Committee (SCC) that meets monthly to review the service coordination process. This group, made up of stakeholders in the child-serving system and a parent representative(s), will be responsible for oversight and evaluation of the service coordination process. Specific responsibilities of the SCC include:

  • reviewing service coordination plans
  • identifying and brainstorming around gaps in service and forwarding this information to the Council Governing Board
  • funding decisions including pooled funding and potential reallocation of funds to community based, preventative, family-centered services
  • monitoring the effectiveness of the service coordination process and updating as needed
  • the creation of a plan to most effectively utilize behavioral and non-behavioral health money for children and families in Tuscarawas County
  • review of children placed outside of the home during the service coordination process to determine alternatives that may have allowed the child to remain in the home and community
  • review of children placed outside of the home during the service coordination process to monitor and track placements to assure continued progress, appropriateness of placement, and plan for discharge
  • the resolution of case disputes through the Dispute Resolution Process
  • the creation of, in conjunction with the Council Director and service coordinator, goals of the Tuscarawas County Service Coordination Mechanism. These goals will be reviewed semi-annually at SCC meetings to monitor progress.

The SCC will include: the superintendent of Tuscarawas County Board of Developmental Disability or a designee, the Superintendent of Tuscarawas County Board of Health or designee, the Director of the ADAMHS Board or designee, the Director of Tuscarawas County Job and Family Services or designee, a representative of Tuscarawas County Juvenile Court, at least one representative from the Tuscarawas County school system, and a parent representative. The service coordinator will be in attendance at all SCC meetings and will be included in discussion and decision making as appropriate.

The committee will elect a chairperson, treasurer and secretary to serve a 12 month term to be renewed each January.  Individuals can be re-elected to the positions for no more than three subsequent terms.  The chairperson will be responsible for the monthly meeting agendas, facilitating monthly meetings, and lead the dispute resolution process. The secretary will be responsible for minutes and correspondence related to the SCC meetings. The treasurer will be responsible for monitoring financial reports related to funding that impacts the delivery of and resources related to service coordination.

The Tuscarawas County Family and Children First Council acknowledges the importance of outcome measures completed by families and providers as a source of vital information regarding the service coordination process. A tool will be utilized through the service coordination process and reported on semi-annually by the service coordinator at SCC meetings.   Updates and changes to the service coordination mechanism will occur based on the feedback from the outcome measure and other sources. Additionally, the SCC will provide this or other data to Ohio Family and Children First Council upon request for the purpose of evaluation.

Protecting the Family's Confidentiality

Protecting the confidentiality of all personal information disclosed during service coordination meetings or contained in the comprehensive family service coordination plan is a priority. The files created through the service coordination process are considered the property of the Tuscarawas County Family and Children First Council and will be maintained at the office site.

A privacy and confidentiality statement will be distributed at the initial meeting and all members are required to read and sign it.  Additional members will be asked to sign the same statement when they are brought into the family team meetings.  Families will be asked to complete a release of information so team members can share information and services can be coordinated.

Records that are created through the service coordination process will be managed in accordance with Ohio Revised Code and HIPAA.  When questions arise related to access, public inspection, disclosure, and confidentiality, the Tuscarawas County Family and Children First Council will rely on Ohio Revised Code and HIPAA to determine the most appropriate course of action.

Children in Placement/Alleged Unruly

Maintaining children in their families and in the community when possible and safe is a priority for the Tuscarawas County Family and Children First Council.   To meet this end, the focus of the service coordination process is as much prevention as it is intervention.  It is the hope of Council that children will be referred at a younger age to allow local services and collaborative efforts to stabilize a situation prior to a child entering middle adolescence.  Council is aware, however, that there will continue to be cases where there is a potential of out-of-home placement or a risk of court involvement.

While it is ideal to identify and coordinate care at a younger age, the Tuscarawas County FCFC is aware that there will continue to be children that do not obtain the services they need and are unable to maintain in their home environment. When this is the case, resources will continue to be pooled to manage the child’s care in a placement and step the child down to a less restrictive environment as quickly as appropriate.  When there is a risk of placement for a child, service coordination will be a priority to identify solutions/alternatives/resources to allow the child to remain in the community when possible.  This process will always focus on the least restrictive environment for the child.  When a child involved in the service coordination process is placed outside of the home on an emergency basis, a service coordination meeting with occur within ten days. The placing agency/system will notify the service coordinator who will schedule the meeting. The service coordinator will present information related to children in placement during the monthly Service Coordination Committee meetings.

Tuscarawas County Family and Children First is cognizant that Council’s recommendations do not usurp the recommendations of other governmental agencies, i.e. Juvenile Court, Job and Family Services, but will provide service coordination in the attempt to divert a youth from court.  This opportunity exists for all cases where a youth is alleged delinquent and/or unruly and Juvenile Court sees service coordination as a diversion option or where providers or school personnel identify behaviors that could be an early indicator of potential delinquent and/or unruly behavior.

Dispute Resolution

This dispute resolution policy is a plan to address disputes that have not been resolved despite attempts to do so.  This policy pertains to agencies/members of Council and their provision of services to children, as well as families who receive services through the service coordination process and will be monitored and managed through the Service Coordination Committee. Parents or custodians shall use existing local agency grievance procedures to address disputes not involving service coordination. It is understood that any family involved in Help Me Grow (HMG) will be aware of and have received information regarding procedural safeguards from their HMG service coordinators. A hard copy of the HMG procedural safeguards is also available to families through the Tuscarawas County Family and Children First Council (330-343-2286) or through a link on the Tuscarawas County Family and Children First website (http://tuscfcf.org/).

In cases where the situation is considered an emergency, such as rights violations of children and families or placement concerns, the dispute resolution process will be expedited. Non-emergency cases may extend past the deadlines listed below as long as the Council responds with a written determination of its findings no later than 60 days after the initiation of the dispute process. Parents and custodians will be informed of the option of dispute resolution throughout the Service Coordination process during the assessment session and on an ongoing basis as needed.

Council members agree that disputes which involve the utilization of pooled funds from any agency shall be resolved without regard to the eligibility guidelines of the individual agencies, limited only by the availability of the funds in the pool.  The Council members agree that disputes which involve the utilization of direct agency funds shall be resolved in accordance with individual agency eligibility guidelines and available funds.

The Service Coordination Committee (SCC), in keeping with the overall emphasis of the County Service Coordination Mechanism, shall conduct the dispute resolution process with a primary emphasis on responding to family needs in a timely fashion.  SCC will be mindful of the impact that the dispute resolution process may have on the well being of families and children.

To that end, the Council agrees and sets forth in this policy that:

  • No services shall be withdrawn (terminated) from families involved in this dispute resolution process during the dispute resolution process unless the family chooses to discontinue the service;
  • Every effort shall be made to provide interim services to serve crucial needs, where possible, in a collaborative fashion, pending final resolution of the process;
  • The collaborating agencies and groups represented in this policy subscribe to the principle that, wherever possible, levels of appeal shall be waived so that a speedy resolution of the process may be achieved; levels of appeal are designed not to represent automatic steps, but to serve as backup to the ongoing process of collaboration to which the Council members are committed as their primary means of service provision, and to provide a fail-safe mechanism to maximize the chances that disputing parties will come to voluntary agreements reflective of unequivocal commitment to service plans.
  • Families shall be involved at each level of the dispute resolution process; assistance in understanding procedural methodology shall be provided if needed, unnecessary professional jargon and unnecessary technical language shall be avoided in oral and written communication with families and families shall be afforded the opportunity to be represented by a person of their choosing during the process, if they so desire.

Level I.  When a request for dispute resolution is received, the SCC chairperson shall convene a meeting of the involved persons/agencies within 7 working days. If there is no chairperson, then the Council Chairperson shall convene the meeting.  The purpose of the meeting shall be to clarify and resolve the issue or issues at dispute as they (it) have a bearing on the appropriate courses of action, agency responsibility, type, amount, and appropriateness of services and/or funds for services not otherwise available.  The issues shall be identified and resolved within 7 working days of the time that the meeting is convened.  This deadline may be extended if necessary and mutually agreed upon by the involved parties.  No change in services may occur during this dispute resolution process at any stage.

Level II.  If the issue remains unresolved, the SCC chairperson may contact the
Service Coordination Committee members as well as Agency Directors within 7 working days from the failure to resolve the dispute.  The SCC chairperson shall be responsible for this meeting and preparing a resolution within 7 working days of their charge to resolve.  In the event that the chairperson of the SCC also is the Director of an agency involved in the dispute, the meeting shall be called by a Tuscarawas County Commissioner or his/her designee.  The 7 day time limit for resolution may be extended as necessary if all parties mutually agree.

Level III.  Should the Service Coordination Committee be unable to resolve the issue at Level II, they may refer the dispute to the Governing Board of the Council for review and recommendation. The Governing Board shall exert every effort to facilitate a final negotiated resolution.  The same time frames that applied to the previous levels also apply here.

Level IV.  In the event that all efforts referenced above have not reached resolution of the dispute, the entities may, within 7 working days, file a motion with the Juvenile Court, asking for a hearing on the matter.  The Juvenile Court Judge shall hold a hearing on the motion to resolve the dispute. SCC/Council will provide all historical information including interagency assessment or treatment information related to the dispute to the Juvenile Court Judge. The Juvenile Court Judge will have final authority in the process.

Individual resolution level time lines may be waived by mutual agreement of all disputing parties.  Notwithstanding individual level time lines and any waivers thereof, the total time line for written determination of findings regarding the the dispute resolution process shall not exceed 60 days except if waived by mutual agreement of all parties involved.

It should be noted that the Council recognizes a clear distinction between a dispute involving systemic resources and those legitimate disputes which a family or service recipient may have with the services of an individual agency.  These grievances are more properly addressed within the grievance or due process procedures of the individual agency.