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ECI: Making It Work Case Management

Moving on to case management

6.1 Moving on to Case Management

Notes:

MIW SC:

Case management, sometimes called service coordination, is an integral part of ECI services; therefore it is important for all staff to be familiar with the basic requirements of this service.

This service starts when a child is referred to an ECI program. Every child who enrolls in ECI will have an IFSP that documents the case management needs for the child and family, and the procedures the family and the team will use to meet those needs. We're addressing case management now because it relates to all of the other steps we've looked at so far -- from referral and initial contact through service delivery, and beyond.

What is it?

6.2 What is it?

Notes:

MIW SC:

Let’s get started by reviewing the basics of case management. Case management is a service that is mandated by IDEA. It is active and ongoing and is intended to assist and enable a child and the child's family to receive the rights, procedural safeguards, and services that are authorized under the state's early intervention program.

Review of SC Responsibilities

6.3 Role of the Service Coordinator

Notes:

MIW SC:

Let’s review what you’ve learned in the module so far about the roles and responsibilities of Service Coordinators as case management service providers.

Now we’re going to discuss the role of the Service Coordinator in each of these five areas; Intro, Referral& Initial Contact, Evaluation & Assessment, IFSP, and Service Delivery

6.4 Introduction to the Module

Notes:

In the Introduction to the module, you learned about important aspects of the Service Coordinator's role:

• Service Coordinators are part of a team assigned to all enrolled children and families

• The Service Coordinator has a special role on every team. He or she is the single point of contact for the family. A Service Coordinator is assigned to each family at referral so the family knows who to contact.

• The Service Coordinator helps families understand their rights in ECI

• Service Coordinators help families gain access to ECI services

You also saw that some responsibilities are unique to the Service Coordinator, but all team members are responsible for other aspects of ECI services. For example:

• All team members establish rapport with the family.

• Also, all ECI services must be culturally sensitive, so all team members must cultivate their ability to be culturally sensitive. Being a good listener is helpful. To do that, you need to be aware of your own cultural values and biases. This is especially important for the Service Coordinator as he/she is often the first person from the ECI program to contact the family.

Question: What does it mean to be the single point of contact for the family?

Answer: Having a single point of contact means the family only has to contact one person to have a need addressed or a question answered. This doesn’t mean that the family can’t talk to other team members about needs or questions they may have. If the family brings up a question or identifies a need during a service delivery visit, the team member should relay this information to the Service Coordinator so it can be addressed.

Question: What is cultural competence?

Answer: The ability to interact effectively with people of different cultures and socio-economic backgrounds. It includes: Awareness of one’s own cultural world-view, Attitude toward cultural differences, Knowledge of different cultural practices and world-views, Cross-cultural skills

6.5 Referral & Initial Contact

In the Referral and Initial Contact section of the module, you saw the Service Coordinator:

• Makes the initial contact with the family and provides information about the ECI program and family rights. The contact with the family must be “timely” according to program requirements.

• May recommend participants for the evaluation team, based on referral information and information from the family gathered from the initial contact.

• Schedules and facilitates all pre-enrollment activities

• Shares the referral information with the team

• Provides information regarding the evaluation process and roles of the team to prepare the family for the evaluation

• Gives notice and gains informed consent

• All team members:

• Review information already collected: for example, referral form(s), family feedback, medical information.

• Begin building rapport with the family

• Ensure procedural safeguards and informed consent for evaluation

6.6 Eligibility (Evaluation & Assessment)

Notes:

In the Eligibility section you saw that the Service Coordinator is responsible for informing the family that info from the evaluation will be used to develop the plan for services. The Service Coordinator also makes referrals identified by team and prepares the family for the IFSP meeting.

In the Eligibility section, you saw that the other team members ensure information gathered initially related to hearing, vision, and nutrition is carried forward to the risk assessment. Other team members determine if a child is eligible and complete clinical documentation to support the eligibility decision. Finally, you saw that other team members are responsible for informing the Service Coordinator of any referrals that need to be made, while the Service Coordinator is responsible for helping the family access those services.

6.7 IFSP

Notes:

Each staff member has a specific role and responsibilities related to the IFSP

In the IFSP section of the module, you saw the Service Coordinator:

• Implements procedural safeguards related to IFSP development

• Is a member of all IFSP teams

• Ensures IFSP team meets requirements in TAC

• Attends all IFSP meetings, including initial, annual, periodic, the transition steps and services and the transition conference. (You'll learn more about transition in the next section of the module.)

• Collects and documents child and family case management needs, resources and outcomes

All team members ensure procedural safeguards are afforded and everyone encourages family participation. Also, everyone on team must consider all of the info gathered, including the family interview, when developing the IFSP. Finally, in the IFSP section of the module you saw that all team members collect and document child developmental needs, outcomes and family priorities.

6.8 Service Delivery

Notes:

In the Service Delivery section of the module, you saw:

1. Everyone explains to families how ECI services differ from home visiting programs and direct therapy service programs

2. Everyone documents their delivered service, including case management, as specified in TAC.

6.9 Behind the Scenes

Notes:

MIW SC:

The Service Coordinator fulfills several responsibilities that may not be obvious at first glance.

Provide resources. Unlike other ECI services, the Service Coordinator may provide case management services before a child has been determined eligible. This may include providing resources for immediate needs for food, clothing, or housing. It may also include referrals to other resources in the community, such as a parent support group.

Schedule and facilitate meetings. Scheduling meetings is one way the Service Coordinator assures the implementation of procedural safeguards regarding notices of meeting, notices of changes regarding services, and gaining consents for services. Facilitating meetings assures that family rights are protected throughout each ECI process.

Deliver services. Just like all other services, the case management provided by the Service Coordinator must be individualized, based on needs assessment and outcomes developed, and family priorities. Meeting identified needs may require seeking and securing resources and service providers, consultation with community resources, and coordinating services across agency lines. Much of this work is done on the phone, online, or in person with providers outside of ECI.

Case management requires ongoing needs assessment and monitoring of service provision. This may include discussions with other members of the team to determine if the family has shared concerns or changes that may impact family life. It may include reading progress notes of other team members to see progress toward child outcomes and family participation in services. It also includes discussions with the family for their opinions on their engagement in other services, their child’s progress, and satisfactions with services.

Support transition. Service Coordinators also initiate and facilitate the transition process. However, transition is not the sole responsibility of the Service Coordinator. The entire team will have input in developing the transition steps and services in the IFSP. These steps may be implemented by different members of the team. You’ll learn more about transition in the next section of the module.

6.10 Summary of the role

Notes:

MIW SC:

You've learned a lot about the role of the Service Coordinator. Here's a summary of how the responsibilities of Service Coordinators and service providers are similar and different.

Service Providers:

• Conduct the evaluation and reevaluations (6 month for QDD or annual) — share results with the Service Coordinator.

• Participate in the comprehensive needs assessment, both the initial and annual.

• Participate in the IFSP meeting and periodic reviews

• Deliver services

• Assess developmental needs on an ongoing basis

• Share information with the Service Coordinator about the child’s progress, needs and family concerns/requests.

ECI Service Providers and Service Coordinators:

• Knowledge of: Infants and toddlers with disabilities; IDEA Part C, including procedural safeguards; Texas ECI program, including eligibility requirements and how services are provided.

• Give the ECI Message, including how to make a referral.

• Support the family.

• Communicate with team members and the family.

• Collaborate with other service providers and community partners as needed.

• Document services according to rule requirements.

• Participate in transition activities.

Service Coordinators:

• Serve as single point of contact for the family.

• Explain and implement procedural safeguards, including notifications and consents.

• Gather information from family during Pre Enrollment. Share information with other team members.

• Coordinate the evaluation and IFSP team.

• Facilitate/ schedule evaluation.

• Coordinate and lead the comprehensive assessment.

• Coordinate and lead the IFSP meeting.

• Coordinate follow up for identified hearing, vision, assistive technology, VCFS, and nutrition needs.

• Coordinate and follow-up for failed MCHAT screening.

• Assess child and family case management needs.

• Connect families to resources to meet needs.

• Monitor IFSP services to ensure child and family’s needs are being met. Share information with team members as appropriate.

• Facilitate reevaluation (6 month for QDD or annual.

• Coordinate annual comprehensive assessment.

• Coordinate IFSP reviews and lead the meetings.

• Coordinate transition.

6.11 Activity: Parent concerns

Notes:

Now we are going to test your understanding of the differences in responsibilities between the Service Coordinators and Service Providers. Answer the following multiple choice questions about this.

The next two questions are for addressing concerns of Andre’s foster mother.

Question 1: Who is best suited to respond to this concern?

Andre seems hyper and has a hard time settling down after visits with his family. I need some suggestions for helping him calm down when he comes home.

A. Service Provider

B. Service Coordinator

The correct answer is A. Service Provider. The Service Provider would be best able to provide intervention strategies to help the parent with this activity.

Question 2: Who is best suited to respond to this concern?

I’d really like a chance to meet with other foster parents. Do you know of any support groups?

A. Service Provider

B. Service Coordinator

The correct answer is B. Service Coordinator. The Service Coordinator would be best able to answer this question to provide the parent with additional resources and supports.

The next two questions are addressing concerns of Elizabeth’s mother

Question 3: Who is best suited to respond to this concern?

I know she’s just a baby now, but I understand people with Down syndrome will probably need help for their entire lives. How are we going to make sure she’ll always have the help she needs?

A. Service Provider

B. Service Coordinator

The correct answer is B. Service Coordinator. The Service Coordinator would be best able to answer this question to provide the parent with additional resources and supports.

Question 4: Who is best suited to respond to this concern?

She hates being on her tummy I want her to get stronger, and I need some suggestions for keeping her from crying during tummy time.

A. Service Provider

B. Service Coordinator

The correct answer is A. Service Provider. The Service Provider would be best able to provide intervention strategies to help the parent with this activity.

The next two questions are addressing concerns of Riley’s father.

Question 5: Who is best suited to respond to this concern?

I’m really afraid Riley’s going to get kicked out of daycare. They need help with teaching him to follow the rules and not hit.

A. Service Provider

B. Service Coordinator

The correct answer is A. the service provider. The Service Provider would be best able to provide intervention strategies to help the parent with this activity.

Question 6: Who is best suited to respond to this concern?

Riley’s pediatrician thinks he needs to see a developmental specialist. I don’t know what that means, and I’m not even sure what questions to ask.

A. Service Provider

B. Service Coordinator

The correct answers are A and B, Both the Service Coordinator and Service Provider. Both the Service Coordinator and the Service Provider would be able to answer this question to provide the parent with additional resources and supports.

Team Communication

6.12 Communication between team members

Notes:

MIW SC:

Establish an effective way for the team to communicate

The Service Coordinator is responsible for sharing referral and initial contact info with the team, but after that, information sharing becomes a two-way street. Families may share concerns with another team member, rather than the Service Coordinator. When this occurs, the team member should listen attentively to the family’s concern. She may want to review with the family the Service Coordinator’s role in helping the family address their needs. She should also share the concern with the Service Coordinator. The Service Coordinator should share relevant information with other members of the team. Communication between team members is critical to building a cohesive system of support for the family.

6.13 Activity 6.2: Sharing information

The following 7 questions test your knowledge on the need to share information with the team.

Question 1: What do you think? Foster-Dad is needing help finding a dessert recipe and wants to know if you know of any good resources that provide easy to make recipes.

A. Share with team

B. No need to share this

The correct answer is B.

This statement does not contain information relevant to the child or team. It is not important to share this information with the whole team.

Question 2: What do you think? Foster-Mom mentions to the EIS that Andre’s CPS caseworker thinks they may be moving Andre to a family placement soon.

A. Share with Team

B. No need to share this

The answer is A. Share with team.

The Service Coordinator will play a key role in assisting with Andre’s transition to ensure continuity of services. Once the Service Coordinator learns if and when Andre is moving, the Service Coordinator will need to share this information with the team.

Question 3: What would you do? Elizabeth’s mom expresses to the Occupational Therapist she is feeling a little overwhelmed with the diagnosis of Down syndrome. She has a lot of knowledge about Down syndrome, but there are things she wants to talk about with other parents.

A. Keep this information to yourself because the mom was just venting.

B. Share with Elizabeth’s Service Coordinator.

C. Tell the mom she can go to the park and discuss this with other parents there.

The correct answer is B. Share with Elizabeth’s Service Coordinator.

An important part of the Service Coordinator’s role is to help connect families to resources. Without directly asking, Mom is looking for relevant help or other parents she can relate to. This is a great opportunity to involve and receive input from the Service Coordinator.

The next four questions are concerning sharing information about Riley.

Remember the members of Riley’s team are:

• Occupational Therapist

• Speech-Language pathologist

• Licensed Professional Counselor

• Service Coordinator

Question 4: What do you think? LPC noticed Dad was at home during the visit today when he is usually at work. Dad told LPC he lost his job. ? Who else needs to know? (More than one answer may be correct)

A. The Service Coordinator

B. The SLP

C. The OT

D. This information doesn’t need to be shared.

The correct answer is A. The Service Coordinator

This information needs to be shared with the Service Coordinator because she would have the ability to provide information on other community resources to assist the family until dad finds a new job. This change may also affect Family Cost Share.

Question 5: What do you think? Teachers told OT that Riley has played appropriately with the cars and trucks for three weeks. He has met one of his goals! Who else needs to know? (More than one answer may be correct).

A. The Service Coordinator

B. The SLP

C. The LPC

D. This information doesn’t need to be shared.

The correct answers are A, B, C. Since Riley has now met this outcome, the team needs to review the service plan to make sure we are still serving this family in the most appropriate way.

Question 6: What do you think? Mom tells the Service Coordinator Riley cannot stand to have her brush his teeth. Who else needs to know? (More than one answer may be correct)

A. The OT

B. The SLP

C. The LPC

D. This information doesn’t need to be shared.

The correct answers are A, B, C. It’s appropriate to share this information with all team members, as they may each develop strategies to address the concern:

The SLP might have ideas for oral-motor activities that might help Riley be more accepting of having his teeth brushed. The OT may have suggestions for sensory activities. The LPC might share behavioral strategies.

Question 7: What do you think? The OT recommends a weighted vest to help Riley regulate his behavior during situations that make him overwhelmed. Adelia responds that she is concerned about the cost of the vest and isn’t sure that is something the family can afford to buy at this time. Who else needs to know? (more than one answer may be correct)

A. The Service Coordinator

B. The SLP

C. The LPC

D. This information doesn’t need to be shared.

The correct answers are A, B and C.

The Service Coordinator can help Adelia access resources that can assist her with paying for the weighted vest. The OT also needs to provide information to the SLP and LPC about recommending the weighted vest, including when the vest should be used.

6.14 Appropriate Sharing of Information

Notes:

While these are some examples of what needs to be shared and with whom, it is generally a good idea to share information with the whole team so everyone involved is on the same page.

Talk with your supervisor: How do team members share information about children and families at your program?

6.15 SC shares info with team

Notes:

While it is important to share information from the family with the Service Coordinator, it is equally important for the Service Coordinator to relay relevant information to members of the team.

As the single point of contact, the Service Coordinator will receive information from the family and even other team members that is relevant to share with the entire team. Some examples are:

• Concern that the child is not making the expected progress toward his IFSP goals.

• Achievement of an IFSP goal

• Changes in the family’s life that might impact the family’s availability for services or how the child is responding to intervention. For example, an unexpected move, a death of a family member, or a family member’s ongoing illness.

• Decisions about what the family wants to do after their child transitions from ECI.

• Updates on the child’s illness or medical concerns, or updates when the child visits medical specialists.

Here are some possibilities in the stories of the three MIW children.

For Andre:

MIW SC: In discussing services with Andre’s foster-mom, she expressed dissatisfaction to me and said she is not getting enough services for improving his speech. I think this would be a good time to meet as a team to review services.

For Elizabeth:

MIW SC: I met with Elizabeth’s Mom yesterday. She updated me on her recent appointments. She will continue to see the cardiologist about her heart defect. She has scheduled with the ophthalmologist. She also had a Barium Swallow completed and they are waiting for the results. (It is important to keep the team updated on appointments, as the information could affect the way in which services are being provided.)

For Riley:

MIW SC: Riley’s parents have stated the school district is going to test him in a couple of weeks to see if he is eligible for Part B. They have requested the whole team attend the assessment and ARD if he qualifies to make sure all of his background information transfers and to ensure he will receive the best possible services.

Coordinating Access to Services

6.16 Coordinating access to services

Notes:

MIW SC:

Provide early child intervention as part of a statewide, comprehensive, interagency system.

The Service Coordinator coordinates access to the various services

As you get to know the families on your caseload you will quickly discover that they have needs that your ECI program cannot meet. You may wonder why resources to meet those needs seem to be so limited. We have to insert some history here to explain...

Legislators who wrote the first public law to establish an early intervention program for states did a lot of research before developing the law. They looked at what states were already doing for families and interviewed lots of families. They determined that most states already offered health care through Medicaid and private insurance. Other agencies offered funding for child care, housing, food, clothing, and social welfare. Some of those agencies received state and federal funding, others provided services based on local needs and resources. It became evident that no single agency, public or private, could meet all the needs of all infants and toddlers. Therefore, the law was written for states to provide early intervention as part of a statewide, comprehensive, interagency system. To meet the diverse needs of children and families, the interagency system would need to be multidisciplinary and someone would need to coordinate access to the various services. The early intervention Service Coordinator was designated to be that person, the single point of contact for the family.

6.17 Communicating with other partners & agencies

Notes:

MIW SC:

The Service Coordinator has resources to help with this huge task. The first is the team, which includes the evaluation team and the IFSP team if it has different members. All team members must share information about the child and family needs with the Service Coordinator.

Another resource is your agency. Many agencies that contract to provide early intervention services also provide other services to your community. It's important for you to know what those other services are and which ones might help your families.

Local and state agencies are another important resource. Texas offers a broad range of supports and services with a variety of eligibility criteria. All team members should be familiar with services available within their communities and from Texas state agencies.

Finally, federal agencies can be a resource for you as well. Helping families access federal information and resources may be as simple as providing a link to a web site. It might also require helping a family complete an application form. At the federal level, the Office of Special Education Programs (OSEP) requires that ECI maintain interagency agreements with the Texas Education Agency and Head Start/Early Head Start. These interagency agreements are required to promote the collaboration between agencies for a statewide system of early care and education for infants and toddlers and their families.

Federal intent, legislation, and state level MOUs are the foundation of our work, but they cannot take the place of the work you do at your local level, the most important level. Community collaboration can be the most important tool in the toolbox. Successful collaboration requires the participation of all team members. Helping families access needed resources and supports is the work of the service coordinator.

6.18 Looking beyond your agency

Notes:

MIW SC:

As you've seen in this module, IFSP team members have roles in ECI that expand beyond the scope of the team member’s specific discipline. Sometimes that means using techniques that promote a child’s development in more than one domain. Sometimes it means seeking services and situations that benefit the child’s development that are not available from your agency. You play an important role in helping families access services. Are you ready for the challenge?

6.19 Activity 6.3: Community resources

Notes:

MIW SC:

Here's an opportunity to learn more about the resources in your community. Locate the "central directory" -- that's your program's list of community resources. Then use Worksheet for Activity 6.3 to identify how you would assist with the family scenarios using resources available in your area.

As you complete this activity, keep in mind that learning about the available resources for families in your community is an ongoing process. And as your knowledge grows, you need to share what you learn with your program so it can be added to your program’s central directory.

Activity 6.3: Get to know resources in your community. Locate the central directory at your program, or list of community resources. Then identify how you could assist with the following scenarios using resources available in your area.

Family Need/ Scenario:

1. A mother of twins is feeling overwhelmed and needs a break.

2. A family is having issues with transportation around town.

3. A two year old child needs a wheelchair.

4. A family is having difficulty getting diapers, food, or formula.

5. A mother and father are interested in meeting other parents who have children with disabilities.

6. A family needs assistance paying their utility bill.

6.20 Helping family access services

Notes:

MIW SC:

Discussions with all team members about what is needed to support the child and family will help you know what to look for, help you avoid duplication of effort in seeking other services, and identify and address barriers to a family’s ability to access necessary services.

Remember: many of your families will have differences in how they ask for assistance. Also, services will be effective only when the family’s personal preferences are considered. When linking families to community resources, be mindful that not all programs will be effective with all families. Including families in the exploration of resources that works for them is an important function of the team. It is likely families will need to access resources not just during the time they are enrolled in ECI, but even after they transition from ECI services. Learning how to find culturally appropriate supports is an important skill for families to learn and take with them beyond their time with ECI.

Challenging Situations

6.21 Activity 6.4: Challenging Situations

Notes:

MIW SC:

Let's see what you've learned in this section. Consider these challenging situations related to the three children. What would you do in each situation? Record your thoughts. Once completed, discuss the answers with your supervisor.

For Andre:

Imagine you have given Andre’s foster mother the contact information for a foster parent support group twice because she has misplaced it and asked you for it. At your next visit, she tells you she just hasn’t had time to contact them and doesn’t know where she put the information. What would you do if you were the Service Coordinator?

For Elizabeth:

Elizabeth has been acquiring lots of new skills and you think some adjustment may be needed to her services plan. You think some new outcomes may also be needed. You want the Service Coordinator to schedule a meeting to review and change the IFSP.

What type of information would you provide for the Service Coordinator? Why? How would you communicate the information? How would you handle a disagreement if another team member thought the outcomes you suggested are not appropriate?

For Riley:

The SLP tells you she has missed several appointments with Riley and his mother. She goes on to inform you, the Service Coordinator, of mom’s frequent last minute cancellations of visits as well as her feeling that mom is not following through with the recommendations for Riley. In fact, she says sometimes Riley’s mom does the opposite of what she recommends.

As the Service Coordinator, you review Riley’s record and confirm that mom has canceled the last three SLP visits, however has not missed any other service delivery sessions. How would you handle this situation? What other information would you obtain and from whom? What other team members would you communicate with?

6.22 End of Section

Notes:

Congratulations. You have completed section 6, Case Management.

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