County of Los Angeles



County of Los Angeles

Department of Mental Health

Department of Children and Family Services

Intensive Home-Based Services Program

and

Child and Family Team Protocol

Overarching Agreements

The Los Angeles County Department of Children and Family Services (DCFS) and Department of Mental Health (DMH) share an interest in the safety, permanency, and well-being of children and families in Los Angeles County. The two Departments have committed to an ongoing collaborative reform of the child welfare and mental health systems to improve the lives of children and families consistent with the following overarching agreements.

Necessary reform will require the coordination and integration of Departmental initiatives in a manner that is mutually supportive and reinforcing:

a) In many cases, fundamental practice change will be required to achieve the shared goals of DCFS and DMH to provide individualized mental health services to children in their own homes or family settings that meet their needs for safety, permanence and;

b) Practice change should be informed by best practice and evidence-based practice standards, benefiting from significant learning in both the child welfare and mental health fields in recent years;

c) Planning, implementation, and modifications to practice should be based on the analysis of quantitative and qualitative data regarding client needs and strengths, service delivery approaches, and client outcomes; and

d) The financial supports for these reform efforts will require a redistribution of available funds and their deployment in a flexible and targeted fashion.

Ongoing Objectives

The County’s efforts also remain consistent with the objectives of the Katie. A. settlement agreement. The primary objectives of the County Plan are the:

a) Integration and coordination of the County’s child welfare and children’s mental health programs, policies, and practices;

b) Prompt identification of the mental health needs of children served by the child welfare system as well as those at risk of entering the child welfare system coordinated and staged across the child welfare system, including Emergency Response, Family Maintenance, Family Reunification, and Permanency;

c) Provision of quality assessment and flexible treatment services to those in need of treatment in order to reduce removals from family, promote permanency and stability of the child’s living arrangement, and foster child and family well-being;

d) Reduced reliance on congregate care and out-of-home placements for foster youth; and

e) Development of a child and family team planning process and a continuum of intensive home-based mental health services to promote family stability, reduce out-of-home placements, and provide an alternative to congregate care.

Los Angeles County Vision and Practice Principles

Ensuring that the needs of children are identified and that individualized, Intensive Home-Based Services to meet their needs and build on the strengths of their relatives and foster families are provided in order to increase placement stability and permanency requires a fusion of practice principles from child welfare and children's mental health. The primary sources for this fusion are the Surgeon General's Report and principles proposed by the Katie A. Panel, which were similar to the R.C. principles in Alabama (R.C. v. Hornsby) and the "Arizona Vision" for behavioral health services in the J.K. settlement (J.K. v. Eden), as well as those associated with the Los Angeles County Wraparound and Children’s System of Care principles.

This fusion of practice principles from child welfare and children's mental health is organized around the three main elements of a system of care approach: family strengths/child needs-based approach, multi-agency collaboration in the community, and cultural competence. The three guiding elements, representing the “Los Angeles County Vision” for the delivery of mental health services for children and youth served by the child welfare system and the associated practice principles are:

1. Services are driven by the needs of the child and preferences of the family and are addressed through a strengths-based approach

• Children and families are more likely to enter into a helping relationship when the worker or supporter has developed a trusting relationship with them. Staff and families work together as partners in relationships based on equality and respect.

• The quality of this relationship is the single most important foundation for engaging the child and family in a process of change.

• Children and families are more likely to pursue a plan or course of action that they have voice and choice in designing.

• When children and families see that their strengths are recognized, respected and affirmed, they are more likely to rely on them as a foundation for taking the risks of change. Programs focus on families' strengths and enhance their capacity to support the growth and development of all family members, adults, youth, and children.

• Assessments that focus on underlying needs, as opposed to symptoms, provide the best guide to effective intervention and lasting change.

• Plans that are needs based, rather than driven by the availability of services, are more likely to produce safety, stability and permanency.

• Children do best when they live with their family or kin or, if neither is possible, with a foster family. Siblings should be placed together. Children should rarely be placed in group or residential care and only when their needs cannot be met by intensive services while they live with their family, kin or a foster home. Group or residential care should not be long-term and should lead to permanent family placement.

• Children receive the care and services needed to prevent removal from their families or, when removal cannot be avoided, to facilitate reunification, and to meet their needs for safety, permanence, and stability in their placements, whenever possible, since multiple placements are harmful to children and are disruptive of family contact, mental health treatment and the provision of other services.

• Incentives are provided for scientifically-proven and cost-effective prevention and treatment interventions that are organized to support families, and that consider children and their caregivers as a basic unit (e.g., home-based treatment, intensive case management, family therapy).

• Children receive care when they need it, not when they qualify for it.

2. The locus and management of services should occur in a multiagency collaborative team and are grounded in a strong community base

• Children experience trauma when they are separated from their families. When children must be removed to be protected, their trauma is lessened when they can remain in their own neighborhoods and maintain existing connections with families, schools, friends and other informal supports.

• Decisions about child and family interventions are more effective when the family's team makes them. Families should always be core members of the team. The family participates as a decision-maker in collaboration with members of the multidisciplinary team and a facilitator who assists in the coordination of services and supports.

• Coordination of the activities of everyone involved is essential and works most effectively and efficiently when it occurs in regular face-to-face meetings of the family team.

• The family's informal helping system and natural allies are central to supporting the family's capacity to change. Their involvement in the planning process provides sustaining supports over time.

• Success in school is a reliable predictor of child well-being. When the direction of planning for safety, stability and permanency is fully integrated with school plans and services, children are more likely to make progress.

• Common terminology must be used to describe children's well-being (emphasizing adaptive functioning and taking into account ecological, cultural, and familial context) in order to facilitate service delivery across systems.

• Issues of confidentiality must be addressed in ways that respect a family's right to privacy, but encourage collaboration among providers in different systems.

• Youth must be included in treatment planning by offering them direct information, in developmentally appropriate ways, about treatment options. As much as possible, youth should make choices about preferred intervention strategies.

• Untreated mental health problems place children and youth at risk for entering the juvenile justice system. Mental health programs designed to divert youth with mental health problems from the juvenile justice system must be supported.

• An infrastructure must be provided for cost-effective, cross-system collaboration and integrated care, including support to providers for identification, treatment coordination, and/or referral to specialty services; and the development of integrated community networks to increase appropriate referral opportunities.

3. The services offered, the agencies participating, and programs generated are responsive to cultural context and characteristics

• Many of the services and resources that children and families find most accessible and responsive are those established in their own community, provided within their own neighborhoods and culture. A comprehensive and culturally competent system of services and supports for all children should be available and accessible to children and families in their respective local communities.

• Programs acknowledge cultural differences, provide culturally competent services, and affirm/strengthen families’ cultural, racial, and linguistic identities, while enhancing their ability to function in a multicultural society.

• Reunification occurs more rapidly and permanently when visiting between parents and children in custody is frequent and in the most normalized environment possible (office based visits and supervised visits are the least normalized environment).

• Children in foster care who are transitioning to adulthood are most successful in achieving independence when they have established relationships with caring adults who will support them over time.

• The system of services and supports should be sufficiently flexible to be adapted to the unique needs of each child and family. Services and supports best meet child and family needs when they are provided in the family's home or for children in custody, the child's current placement. Services should be flexible enough to be delivered where the child and family reside.

• A menu of seamless (non-categorical) mental health, substance abuse,

and related support services and resources should be provided and be

fair, responsive, and accountable to the families served.

Overview of the Child and Family Team* and Intensive Home-Based Services Models

The Los Angeles Vision and associated practice principles are brought to life through the implementation of Intensive Home-Based Services with a Child and Family Team planning process.

Intensive Home-Based Services

In order to meet the needs of a large number of underserved DCFS children presenting with intensive mental health needs requires a change from office-based, once a week services to care delivered both to the child and caretaker in their home and community, often several times a week. Intensive Home-Based Services is an individualized, child-focused, family-centered approach that is offered by a range of contracted mental health providers. Examples of current

*Child and Family Team is the term being used in this document to help differentiate it from the current SB 163 Wraparound program.

Intensive Home-Based Services programs in Los Angeles County include Wraparound, Children’s System of Care (CSOC), Full Service Partnerships (FSP), Multisystemic Therapy (MST), Multidimensional Treatment Foster Care (MTFC), and Intensive Treatment Foster Care. Based upon estimates of current Intensive Home-Based Services capacity in Los Angeles County and the need for such services, the departments estimate that capacity for these kinds of services will need to be expanded to serve approximately 2800 additional children and youth.

Based on the federal Child and Adolescent Service System Program (CASSP) principles and the literature on evidence-based services for severely emotionally disturbed (SED) children and families, Intensive Home-Based Services can be defined as:

a well-established intervention designed to meet the child's needs in his/her birth, kinship, foster or adoptive home and in the community where the child lives. The planning and provision of Intensive Home-Based Services require an individualized process that focuses on the strengths and needs of the child and the importance of the family in supporting the child. Intensive Home-Based Services incorporate several discrete clinical interventions, including, at a minimum, comprehensive strength-based assessment, crisis services, clinical case management, family teams, and individualized supports including one-on-one clinical interventionists. These services must be provided in a flexible manner with sufficient duration, intensity, and frequency to address the child's needs and guide his/her caregivers.

Individualized services must be designed to meet the unique needs of each child and build on the child's and family's strengths. It is essential to have birth, kinship, adoptive and foster families involved in planning services with professionals from mental health, child welfare, school and other agencies and the family's informal supports. The complex needs of these children require integrated services, and team planning is essential and cannot be separated from the interventions. (See description of Child and Family Teams below). Providers will require training and coaching to incorporate the clinical principles and approaches of evidence-based practices as they design culturally-competent Intensive Home-Based Services.

Effective services for emotionally disturbed children require enhanced care coordination, often daily individual clinical interventions for the child, and guidance for caregivers (including teachers) for which traditional outpatient therapy is not sufficient in number of hours, flexibility, or family functioning focus. Safety, stability and permanency for children are most likely when birth, kinship, adoptive and foster families are guided to manage their behaviors and do not have to travel to receive intensive services. Usually the team will not plan office-based services for the child and family, with the exception of medical services and medication management that cannot be provided in the home or community. Intensive Home-Based Services do not designate a position to provide one-on-one support to the child (such as a mentor or TBS) or to guide the caregiver (such as a parent advocate or a family specialist): the team decides whether a therapist or a paraprofessional can most effectively meet this child’s needs and the provider ensures that this person has the clinical training and supervision to do so. Usually the team will provide crisis services so the child and family know the individuals helping them in a crisis (instead of an unknown mobile crisis team).

When the child is living with kin or a foster family, not only will that family be provided guidance for caring for the child, but the prospective permanent home where the child is likely to be placed will also be prepared for meeting the child’s needs with similar Intensive Home-Based Services during visits. When a family has several children, the team will likely include several individuals supporting different children. When the child is a teenager, he/she will be actively involved in the team with the goal that she/he will agree with his/her needs list and contribute to the design of services.

Intensive Home-Based Services represent a “WHATEVER IT TAKES” approach and may include, but are not limited to:

• A comprehensive assessment of needs and strengths

• Targeted case management with 24/7 access to services

• Parent/relative/foster parent training and coaching

• Individual and family therapy

• Crisis intervention

• Medication management

• Skills training and other rehabilitative services

• Behavior coaching and other skill building with the child, including support during school and after-school activities

• Access to flexible funds to support non-billable activities, such as:

o Respite care

o After school activities

o Tutoring

o Behavioral incentives

o Recreational activities

o Creation of an informal support activity

o Emergency rent subsidies

o Other one time expenses

In creating additional service capacity to provide this approach, the emphasis will be on rehabilitation and support services that can be claimed to EPSDT. Arizona is an example of a jurisdiction that has used such services to develop their intensive in home services programs, especially those that focus on direct support services. We will need to compare the covered services provided in Arizona, as described in the Arizona Department of Health Services-Division of Behavioral Health Services Covered Services Guide with those contained in the Los Angeles County Organizational Providers Manual to determine whether these kinds of services can be claimed within our system. For example, Arizona defines these types of services as follows:

Rehabilitation Services (page 44)

“Rehabilitation services include the provision of education, coaching, training, demonstration and other services including securing and maintaining employment to remediate residual or prevent anticipated functional deficits. Except for cognitive rehabilitation, which is billed using a CPT (Physicians’ Current Procedural Terminology) code, rehabilitation services are billed using HCPCS (Healthcare Procedure Coding System) codes. Rehabilitation services include:

• Skills training and development and psychosocial rehabilitation living skills training

• Cognitive rehabilitation

• Behavioral health prevention/promotion education and medication training and support (health promotion)

• Psychoeducational service (pre-job training and job development) and ongoing support to maintain employment (job coaching and employment support)”

Support Services (page 77)

“Support services are provided to facilitate the delivery of or enhance the benefit received from other behavioral health services. These services have been grouped into the following categories:

• Case management

• Personal care services

• Home care training family services (family support)

• Self-help/peer services (peer support)

• Home care training for home care client (HCTC)

• Unskilled respite care

• Supported housing

• Sign language or oral interpretive services

• Non-medically necessary covered services (flex fund services)

• Transportation”

Each of these services is further identified within the Arizona Covered Services Guide.

The target of services is the child, though services may be delivered to family members in order to accomplish the goals of the child’s treatment. On this subject, the Arizona Covered Services Guide says:

For purposes of service coverage and this guide, family is defined as:

“The primary care giving unit and is inclusive of the wide diversity of primary care giving units in our culture. Family is a biological, adoptive or self-created unit of people residing together consisting of adults(s) and/or child(ren) with adult(s) performing duties of parenthood for the child(ren). Persons within this unit share bonds, culture, practices and a significant relationship. Biological parents, siblings and others with significant attachment to the individual living outside the home are include in the definition of family

In many instances it is important to provide behavioral health services to the family member as well as the person seeking services. For example, family members may need help with parenting skills, education regarding the nature and management of the mental health disorder, or relief from care giving. Many of the services listed in the service array can be provided to family members, regardless of their enrollment or entitlement status as long as the enrolled person’s treatment record reflects that the provision of these services is aimed at accomplishing the service plan goals (i.e., they show a direct, positive effect on the individual). This also means that the enrolled person does not have to be present when the services are being provided to the family members.

For situations in which a family member is determined to have extensive behavioral health needs, (e.g., substance abusing parent) the family member her/himself should be enrolled in the system. It is recognized that the ability to provide services to non-title XIX/XXI eligible family members may be limited depending on the availability of funds.” (page 10)

These services are often provided by high school or bachelor level staff who are not mental health professionals, but who are supervised by licensed mental health professionals.

Intensive Home-Based Services increase and decrease in intensity and duration as needed, with the possibility of daily interventions over durations longer than a year, while being flexible to taper efficiently or increase quickly to prevent a crisis, consistent with the practices of evidence-based services. Such services must also be responsive to the urgent episodic and longer-term critical needs of children and families.

This process starts with the initial contacts made by DCFS with the child and family at intake and by the co-located mental health staff, and continues with the immediate response home visit, through the assessment process and initiation of services by the provider and continues with case management and the Child and Family Team. An important goal of this effort is to design Intensive Home-Bases Services to be available immediately when urgent needs arise and not to require a complex or lengthy referral and authorization process, a comprehensive assessment, or the convening of a Child and Family Team or Team Decision Making meeting.

Intensive Home-Based Services also promote the use of natural or informal support systems which do not involve formal mental health services and which are consistent with the cultural and community practices of the child and family. These informal supports may include activities, community institutions, individuals outside the immediate family, and community beliefs that can enhance and support the clinical services associated with the Intensive Home-Based Services programs. Over time, the reliance on professional services is expected to diminish as these informal supports are identified and used to support the child and family. The Informal Services Tracking Form (See appendix xx) is an example of a tool that can be used to monitor the use of these services.

Child and Family Teams

A Child and Family Team is a gathering of family members, friends, members of the family’s faith community, and professionals who join together to jointly develop an individualized plan to strengthen family capacity, to assure safety, stability and permanency and to build natural supports that will sustain the family over time (the description by permission of The Child Welfare Policy and Practice Group). The Child and Family Team evolved from the way that families form their own natural helping system to meet needs and solve problems. The Child and Family Team is the forum in which these individuals come together to help the family craft and change services and supports by:

• engaging and building trusting relationships with families

• developing capable teams around the child and family

• using the team to discover strengths and needs, especially the underlying needs that have produced the circumstances and behaviors requiring system attention

• developing individualized plans with strong child and family involvement that employ child and family strengths in the plan/course of action to resolve critical needs

• implementing plans in timely and effective ways

• tracking and adapting plans, based on results, in order to develop safety and sustainability beyond formal system involvement

Child and Family Teams operate with a Facilitator and access to a Parent Partner.

The Child and Family Team Facilitator is the person who assures that the Los Angeles County Vision, practice principles, and the steps of the Child and Family Team process are provided to the child and family in a timely manner with high fidelity. The facilitator is generally a clinical staff member of a mental health agency who has been trained and credentialed in the Child and Family Team process, though the role of the facilitator may be assumed by other members of the Child and Family Team.

Parent Partners are former primary caretakers of children of either the mental health or child welfare system. Parent Partners are members of the Child and Family Team and facilitate/support the engagement and involvement of family in the process. In this role, they may assume a number of responsibilities, including serving as a community liaison/outreach coordinator, acting as a family advocate, providing informal supports to families, developing resources for families, evaluating activities of the child welfare and mental health service systems, providing training to professionals, and serving on various committees.

Families in which children need protection also require a supportive circle of allies that includes extended family, friends, neighbors, other members of the family’s informal support system and community resources like churches and civic organizations, as well as professional supports from a variety of community agencies. Sometimes families in crisis can, themselves, mobilize part of the support system. However, they often need assistance in structuring this process and developing a full array of members for the team. Partners who see their role as helping the family in the change process can make a more effective contribution if a team facilitator is responsible for bringing the team together.

These supports should be brought together in a Child and Family Team at a time and place accessible to the family, focusing on safety and permanency, engaging team members, assessing needs, facilitating the development of a plan, recording specific responsibilities of team members, coordinating actions, ensuring that steps are accomplished and monitoring progress towards change. Team members are critical to identifying strengths, identifying options for accomplishment of goals, contributing their skills and resources as family supports, holding others accountable for their commitments, identifying critical decisions and providing feedback about progress. Whether the family is functioning well enough to organize its own team or needs help with facilitation, it is vital that the family feels that they are central and influential participants in the team and not just the passive object of the team’s efforts. Bringing a team together contributes a variety of constructive benefits including:

• Preventing abuse and neglect and speeding permanency

• Preventing removal and placement disruptions

• Strengthening engagement with families and older youth

• Improving the quality of assessments about strengths and needs

• Increasing the likelihood of matching the appropriate service to needs

• Identifying kinship placement opportunities

• Increasing the variety of options for solutions

• Increasing the capacity to overcome barriers

• Creating a system of supports that will sustain the family over time and provide a safety net after agency involvement ends

The Child and Family Team is a solution-focused method that draws on the family’s past success in solving problems, determines circumstances when the family is currently able to solve the problem (even if only for a brief period) and develops the family’s vision for a preferred future. The Child and Family Team can work to strengthen families in a way that they can find immediate solutions to needs and provide long-term solutions for issues related to safety, permanence and well-being.

The Child and Family Team is based on a number of family centered beliefs and practice values, including:

• The focus should be on needs rather than symptoms. Unless the underlying conditions producing the behavior are addressed, symptoms will only be suppressed, to reappear later.

• People are capable of change and most people are able to find the solutions within themselves, especially when they are helped in a caring way to identify that solution.

• All people and families have strengths. Strengths are discovered and confirmed when people are affirmed, listened to, acknowledged and encouraged. Recognizing strengths in families builds a foundation for a trusting relationship and a functional platform for change.

• A family is more invested in a plan in which the family members believe that they are full partners in the decision making process.

• When extended family members and friends become part of a team, they frequently identify solutions that no formal system would be able to generate.

• Family and friends can provide long-term care, vigilance and commitment in a way that no formal helping system can. That support during a Child and Family Team Conference helps a family take supported risks toward change. Kinship and informal supports also provide a level of accountability that is unique to their relationship with the family.

• Child and Family Teams are needs driven based on the child and family’s unique needs), not event driven (only at predetermined points in the casework process or tied only to placement decisions), or service driven (fitting the family into a service).

• A major focus of the Child and Family Team is the development of a sustainable family team that evolves and continues beyond formal system involvement.

The Child and Family Team acknowledges that the team member with whom the child and family has the most trusting relationship, even if it is an informal support, can facilitate the process if they have been well-trained and have developed the practice skills referenced previously. This recognizes the inevitable necessity of the team members understanding that the Child and Family Team process is not a simple intervention, but rather a process that is owned by the family and can be sustained after all the formal supports are no longer needed.

The tension between the “family-owned plan” and perceived agency obligations is sometimes raised in the implementation of the Child and Family Team, especially related to child safety issues. Child welfare practitioners might ask, for example, if they would be expected to accede to a parents wish for reunification when parental capacity is insufficient to assure child safety. Obviously, the answer to that question is no. In such a circumstance, however, the team could provide an environment where the parent could exercise choices about steps, services and supports through which a safe alternative to removal could be implemented or parental capacity could be most effectively strengthened.

When considering this issue it is important to remember that the Child and Family Team is foremost a planning process. Decision-making is a part of that process, but it is expected that a child and family will have a continuing team with which they develop a trusting relationship lasting throughout their encounter with the system. Many major decisions arise after the team has formed and partnership relationships have been formed. Even in circumstances when the team is newly formed, for example following an emergency removal, the Child and Family team is designed to enlist the family as partners in protecting their children.

Experience has shown that the, “Who decides?” choice rarely occurs when a well- functioning team is operating. Some key elements to avoiding differences and confrontations about decisions are the early involvement and ongoing participation of the child welfare worker and the facilitation process itself. Early in the first meetings with family the team reaches a working agreement with the family about the nature of the challenge or problem(s) facing the family and what success will look like (family’s vision and the team’s mission statement). Any non-negotiables like court orders and child safety and permanency are clearly identified and become part of the plan. Inevitably there will be some circumstances where regardless of family commitment to the plan or decision – or lack of it, circumstances necessitate that the team must conclude with a plan that resolves safety concerns.

One of reasons that Child and Family Teams are effective is that they recognize the family’s strengths and potential capacity, a value that underlies all of the team’s functioning. If the approach to teaming begins with an assertion of control by the professionals, the team conference has turned into a conventional staffing. As practitioners begin to experience the benefits of the teaming process and greater success in actual cases, fears of the potential negative consequences of meaningful family empowerment begin to subside.

Another reason that Child and Family Teams are effective is that they are responsive and adaptive to the unique characteristics of the needs and the services involved. The Child and Family Team remains the constant planning process for the child regardless of the involvement of other services.

The Child and Family Team Process

There are four phases* that comprise the Child and Family Team process model:

1. Engagement and Team Preparation

2. Initial Plan Development

3. Implementation

4. Transition

The use of numbering for the phases and activities as stated in the Phases and Activities of the Wraparound Process is not meant to imply that the activities must invariably be carried out in a specific order, or that one activity or phase must be finished before another can be started. Instead, the number and ordering is meant to convey an overall flow of activity and attention.

* The four phases are a product of the National Wraparound Initiative (attachment xx).

Phase I: Engagement and Team Preparation

The engagement and team preparation sets the groundwork for the entire child and family team process and is predictive, in many ways of the ultimate success of the team. The trust and shared vision with the family and team is established in this phase, which is the fabric that will hold the team together during difficult times. The facilitator meets with the family to hear their story, culture and share their success and concerns for the future. Additionally, the tone is set for teamwork and shared responsibility, which provides an opportunity for the family to understand they are an integral part of the process and their preferences are prioritized.

Within this phase, there are three steps:

1. The Strengths and needs conversation

The Strengths and needs conversation provides essential information from which to build a strength-based, customized individual service plan that respects the unique cultures of children and their families. It provides the foundation for the CFT to develop options, and ultimately a highly individualized plan that is likely to “fit” with this child and family in a way that attracts their commitment to and investment in its success. By identifying strengths, assets and sources of support, the Strengths, Needs and Culture Discovery expand the array and volume of resources available to the team beyond formal, categorical services.

2. Crisis stabilization

Crisis stabilization describes actions that address concerns about immediate safety, security and well- being such as those related to medical needs, severe psychiatric symptoms, homelessness, behaviors of a child that might place others in jeopardy, or ongoing domestic violence. Any child entering foster care because of abuse or neglect is considered to be in crisis, due not only to the abuse or neglect, but also to the trauma of removal from one’s family, and the needs of the child and the child’s new caregivers to adapt to their new situation together. In addition to the immediate relief of existing concerns, crisis stabilization attempts to predict potential areas of crisis that may require preventive measures, stabilization, and clearly identified steps to respond should a future crisis occur. As with other activities in this phase, the goal is to do no more than necessary prior to convening the team, so that the facilitator does not come to be viewed as the primary service provider and so that team as a whole can feel ownership for the plan and the process.

3. Engage potential team members

The goal of engaging potential team members is to gain the participation of team members who care about and can aid the youth/child and family, not only during the Child and Family Team process, but after all formal services terminate. The facilitator, together with family members, approaches potential team members identified by the youth and family. The facilitator describes the child and family team process and clarifies the potential role and responsibilities of this person on the team. Ideally, the team will eventually have more informal/family support than formal team members.

Phase II: Initial Plan Development

During this phase, team trust and mutual respect are built while the team creates an initial plan of care using a high-quality planning process that reflects the three guiding principles. In particular, the youth and family should feel that they are heard, that the needs chosen are ones they want to work on, and that the options chosen have a reasonable chance of helping them meet these needs. This phase should be completed during one or two meetings that take place within 1-2 weeks, a rapid time frame intended to promote team cohesion and shared responsibility toward achieving the team’s mission or overarching goal.

Within this phase, there are two steps:

1. Develop an initial plan of care

The facilitator guides the team in a discussion on developing a single, all inclusive Plan of Care (POC) that will cover all the activities and accomplishments of the Child and Family Team (see attachment Five). The family’s vision is discussed, which then guides the team in setting a team mission. The mission statement is the overarching goal that will guide the team through the phases and, ultimately, through transition from a formal Child and Family Team. The team also documents all the family’s strengths and all identified needs, which form the strategies for the team. The CANS tool, if not already completed as part of the initial gate keeping process, should be completed as part of this step. The strengths and needs should also reflect the contribution of the other team members and at a minimum, should address legal and ethical mandates and issues— including confidentiality, mandatory reporting, and other legal requirements—and how to create a safe and blame free environment for youth/family and all team members. Ground rules are recorded in team documentation and distributed to members. In this activity, the team members define their collective expectations for team interaction and collaboration. These expectations, as written into the ground rules, should reflect the three principles. For example, the principles stress that interactions should promote family and youth voice and choice and should reflect a strengths orientation and that important decisions are made within the team and not outside of the team. Once the strengths and needs of the team are identified and the ground rules for working together are established, the facilitator will guide the team in a process to think creatively about strategies for meeting the identified needs and pairing them with the team’s strengths to achieve the desired outcomes. The facilitator will encourage brainstorming that may generate multiple options to resolve one need. Each option is then evaluated by considering which are likely to be effective in helping reach the goal, outcome, or indicator associated with the need; the extent to which they are community based, the extent to which they build on/incorporate strengths; and the extent to which they are consistent with family culture and values.

2. Develop a crisis plan

The facilitator guides the team in a discussion of how to maintain the safety of all family members and things that could potentially go wrong, followed by a process of prioritization based on seriousness and likelihood of occurrence. The family is asked to discuss past crisis and how the family managed them. This history is an important source of information in current crisis planning. The team will develop a proactive and reactive crisis plan that will allow the family to not only avoid potential problems and crisis, but to also have a clear plan when a crisis does occur. Additionally, the facilitator guides the team in discussion of specific roles and responsibilities for each identified situation. This information is documented in a clearly written crisis plan, which stresses first response by team members. The crisis plan is also written in the voice of the family, avoiding “psycho babble.” After each crisis, the team will come together to discuss the efficacy of the plan and make any and all necessary modifications.

Phase III: Implementation

During this phase, the initial child and family team plan is implemented, progress and successes are continually reviewed, and changes are made to the plan and then implemented, all while maintaining or building team cohesiveness and mutual respect. The activities of this phase are repeated until the team’s mission is achieved and the formal child and family team is no longer needed.

There are two steps associated with implementation:

1. Implement the plan

For each strategy in the wraparound plan, team members undertake action steps for which they are responsible. The facilitator aids completion of action steps by checking in and following up with team members. The team repeatedly reviews and monitors progress on the action steps for each strategy in the plan, tracking information about the timeliness of completion of responsibilities assigned to each team member, fidelity to the plan, and the completion of any particular intervention. Using timelines associated with the action steps, the team tracks progress. When steps do not occur, teams can profit from examining the reasons why not. For example, teams may find that the person responsible needs additional support or resources to carry out the action step, or, alternatively, that different actions are necessary.

2. Revisit and update the plan

When the team determines that strategies for meeting needs are not working, or when new needs are prioritized, the facilitator guides the team in a process of considering new strategies and action steps. The facilitator guides the team in a similar process that occurred in the plan development phase, but will also review and evaluate why the initial strategy did not work. The facilitator again, will ask the team to think in a creative and open-ended manner about strategies for meeting needs and achieving outcomes. Multiple options will be encouraged again and then those are evaluated for helping reach the goal and the extent to which they build on/incorporate strengths; and are consistent with family culture and values. The process of team self evaluation and accountability are crucial to the cohesiveness and trust of the team.

The facilitator needs to make use of any available information (e.g., informal chats, team feedback, surveys—if available) to assess team members’ satisfaction with and commitment to the team process and plan, and shares this information with the team as appropriate. Many teams maintain formal or informal processes for addressing team member engagement or “buy in”, e.g. periodic surveys or an end-of-meeting wrap-up activity. In addition, youth and family members should be frequently consulted about their satisfaction with the team’s work and whether they believe it is achieving progress toward their long-term vision, especially after major strategizing sessions.

Teams will vary in the extent to which issues of cohesiveness and trust arise. Often, difficulties in this area arise from one or more team members’ perceptions that the team’s work—and/or the overall mission or needs being currently addressed—is not addressing the youth and family’s “real” needs. This points to the importance of careful work in deriving the needs and mission in the first place, since shared goals are essential to maintaining team cohesiveness over time.

Phase IV: Transition

During this phase, plans are made for a purposeful transition out of formal wraparound to a mix of formal and natural supports in the community (and, if appropriate, to services and supports in the adult system). The focus on transition is continual during the wraparound process, and the preparation for transition is apparent even during the initial engagement activities.

1. Plan for transitioning out of the formal child and family team

Preparation for transition begins at the beginning of the child and family team process, but intensifies as the team meets needs and moves towards achieving the mission. While formal supports and services may be needed post transition, the team is attentive to the need for developing a sustainable system of supports that is not dependent on the Department of Children and Family Services (DCFS). The family is encouraged to continue using the child and family team process, even after it is no longer being provided as a formal service. Specifically, the team will be encouraged to identify current or potential team members for the facilitator role. So, family members and youth, or other supports, will likely take on some or all of the facilitation and coordination activities.

But before the team can graduate, they must prepare a post-transition crisis plan, which includes action steps, specific responsibilities, and communication protocols. Planning may include rehearsing responses to crises and creating linkage to post-team crisis resources. At this point in transition, youth and family members, together with their continuing supports, should have acquired skills and knowledge in how to manage crises. Post-transition crisis management planning should also acknowledge and capitalize on this increased knowledge and strengthened support system in their community. This activity will likely include identification of access points and entitlements for informal/formal services that may be used following the end of the formal child and family team process. Additionally, new members may be added to the team to reflect identified post-transition strategies, services, and supports.

Target Population

The initial target population for Intensive Home-Based Services and the associated Child and Family Teams is those members of the Katie A. class with urgent and/or intensive mental health needs that do not meet the referral criteria for existing intensive home-based programs such as Wraparound, Children System of Care, and Intensive In-Home Mental Health Services. Focal populations for Intensive Home-Based Services, at least initially, will be:

• Children in family or relative placements (including VFM/VFR/FM)

• Children in D-rate placements

• Children in Foster Family Agencies

• Children and families that can be diverted from entering the Child Welfare system through the provision of such services

• Children and families that whose exit from the Child Welfare system can be facilitated by the provisions of such services

Identification of potential children and families to be served by Intensive Home-Based services can be initiated in one of two ways:

1. Urgent Need: Intensive Home-Based Services can be provided in response to urgent child needs for crisis and stabilization services for short periods of time (up to 60 days) without formal authorization in order to prevent a change in placement, or

2. Intensive or Complex Needs: Intensive Home-Based Services can also be initiated at a variety of key decision-making points within the Child Welfare system including Team Decision Making (TDM) meetings, the Multi-Disciplinary Assessment Teams (MAT) process, and/or via screenings and assessments conducted by DMH co-located staff.

We suggest working with John Lyons to develop an abbreviated version of the mental health section of the CANS tool that can be used for screening purposes at these key decision-making points and/or employ several key triggering events, such any of the following within the past 12 months as another way to identify candidates for Intensive Home-Based Services:

• school failure

• delinquency

• substance abuse

• two or more placements

• placement in RCL 10 or above

• victim of trauma or exposure to traumatic event(s)

• history of mental health treatment without positive outcome

Governance:

Planning and oversight of the Intensive Home-Based Services programs and the use of Child and Family Teams requires a collaborative integration of DMH and DCFS efforts. This integration is reflected in the proposed Integrated Behavioral Health Management Leadership Team and the Countywide Care Coordination Unit. It is proposed that DMH assume lead agency responsibility for this effort.

Integrated Behavioral Health Management Leadership Team: The Integrated Behavioral Health Management Leadership Team is jointly staffed by DMH and DCFS administrative leadership (Division Chief/District Chief). The team provides administrative coordination and overall administrative oversight of the Intensive Services programs, including Intensive Home-Based Services (IHBS), Wraparound, System of Care (SOC), Intensive Treatment Foster Care (ITFC), Multidimensional Treatment Foster Care (MTFC), Residentially-Based Services (RBS), Resources Utilization Management Process (RMP), Multisystemic Therapy (MST), Psychiatric Hospitalizations, Community Treatment Facilities (CTF) and Comprehensive Child Services Program (CCSP). The Team would be responsible for the countywide planning, performance measures, client outcomes, flex fund utilization, and overall coordination of the services programs.

Program managers, or their designees from each of the above mentioned programs, would submit a monthly report on referrals by office (SPA), census reports, disenrollments and graduations, and any other requested/required information. Additionally, program managers, or their designees from MAT, FSP, and HUB would be requested to attend to share updates, or changes to their programs.

Ultimately, this team will be responsible for insuring that the emotional and behavioral needs of children and youth under DCFS care are adequately and appropriately met and that all the intensive resources are being utilized appropriately and efficiently. The goals and objectives of this integrated effort are as follows:

Goals:

□ Timely and effectively communicate operational plans for interagency policy directives.

□ Strong and enduring interagency departmental management support and ownership of any given project.

□ Implementation of quality, responsive, and sustainable programs which are valued by the participants.

Objectives:

□ Maintain a consistent protocol (operational plan) for designing and communicating the scope, impact, influence, and parameters of interagency service delivery efforts.

□ Maintain a working framework for identifying strategies for maximizing success.

□ Continue strategies for engaging interdepartmental managers’ support.

□ Continue strategies for identifying and engaging key community stakeholders for participation.

□ Maintain the design team quality indicators.

Countywide Care Coordination Unit: Working in collaboration with the Integrated Behavioral Health Management Leadership Team is the Countywide Care Coordination Unit. This administrative unit is collaboratively staffed by DMH and DCFS at the program manager level and is responsible for the programmatic and administrative oversight of the Intensive Home-Based Services program and the Child and Family Team protocol, including the planning and contracting of services, service authorization, tracking of service fidelity, performance measures, client outcomes, flex fund approval and distribution, and overall coordination of the program. The Countywide Care Coordination Unit is organizationally structured to report to the Integrated Behavioral Health Management Leadership Team, which ultimately reports to DCFS and DMH leadership. The Countywide Care Coordination Unit also has direct communication to line operations and community stakeholders (Please see attachment XXX).

The Countywide Care Coordination unit will use several standardized processes and tools to assist in the management and oversight of the Child and Family Team process and Intensive Home-Based Services.

Child Assessment of Needs and Strengths (CANS) Tool: The CANS was developed by John Lyons, Ph.D. and his colleagues to assist in the management and planning of services to children and adolescents and their families with the primary objectives of permanency, safety, and improved quality in of life. The CANS is designed to be used either as a prospective assessment tool for decision support during the process of planning services or as a retrospective assessment tool based on the review of existing information for use in the design of high quality systems of services.[pic]

An abbreviated CANS tool will be used to assist in determining level of care needs and tracking of service outcomes.

Wraparound Fidelity Index 4.0: The Wraparound Fidelity Index 4.0 (WFI-4) is a set of four interviews that measures the nature of the wraparound process that an individual family receives. The WFI-4 is completed through brief, confidential telephone or face-to-face interviews with four types of respondents: caregivers, youth (11 years of age or older), wraparound facilitators, and team members.

Child and Family Team Plan of Care (POC): The POC is a planning document that identifies individualized strategies, across twelve life domains, addressed to the unique strengths and needs of the child and family. The document also identifies the person responsible for each strategy, including timeframes for completion, the cost and/or resources required, and an update on the outcomes associated with previous POCs. The POC is signed by all Child and Family Team members to indicate their support and ownership of the plan. Initial POCs are submitted and reviewed by the Behavioral Health Management Team within 30 days and then at six month intervals.

Informal Services Tracking Form: The Informal Services Tracking Form is a tool intended to assist the Child and Family Team in reporting and emphasizing the needed transition from formal supports to more informal/community supports. The information is collected by the Child and Family Team facilitator and sent to the Behavioral Health Management Team on a quarterly basis. (Please see attachment XXX).

Referral and Authorization Process

Child and Family Teams and Intensive Home-Based Services are intended for those DCFS-involved children with serious emotional and behavioral problems that are unable to be addressed by existing behavioral health resources. In order to qualify for these services, children must meet the following criteria:

• Be a member of one of the five focal populations

• Qualify for EPSDT

• Meet the medical necessity requirements for EPSDT

• Provide the necessary consent for treatment

• Need intensive services as determined by the criteria described in the Target Population section of this document

• Not more appropriately served by another treatment resource

Intensive Home-Based Services can be provided to children and families for 60 days without prior authorization in situations where an urgent response is needed to prevent removal or replacement of a child. The formation of a Child and Family Team is encouraged in these instances, but not required. If Intensive Home-Based Services are required for longer than 60 days, the provider will need to request authorization from the Countywide Care Coordination Unit.

For children with more ongoing intensive or complex needs, Child and Family Teams should be the service planning process. Child and Family Teams can be initiated by the family via the CSW and/or DMH co-located staff, the child/family’s therapist, teacher, MAT, or other professional working with the family. Some referrals will be generated from the Team Decision Making (TDM) meetings, including those that are part of the Resource Utilization Management Process, held within DCFS Regional Offices. Children and youth who are the subject of these meetings and who meet the criteria will be considered to be “pre-authorized” for service and will referred to the Countywide Care Coordination Unit, composed of DMH and DCFS staff. Ideally, the Intensive Home-Based Services in the SPA would have attended the TDM, so the family and the provider can start the planning process at the TDM. Referrals will be reviewed for appropriateness and those that are deemed appropriate will be “authorized” by the Countywide Care Coordination Unit.

During the period of enrollment, the Countywide Care Coordination Unit will provide oversight of service delivery and outcomes through the monitoring of reports from the provider, including Plans of Care, the Wraparound Fidelity Index-4, the Informal Services Tracking form, and the CANS. Requests for flexible funding will be reviewed by the Countywide Care Coordination Unit.

Enrollment will continue until such time that the CFT requests that services be discontinued or until the child no longer meets medical necessity requirement or it is otherwise deemed that the services are not longer necessary by the Countywide Care Coordination Unit. At such a time, the child and family will be disenrolled from Intensive Home-Based Services.

Funding

The development of Child and Family Teams and Intensive Home-Based Services will require the departments to share funding streams since no single funding mechanism is available to support these efforts. At least one source of funding must be able to be used in a flexible manner to support the work of the Child and Family Team and those intensive home-based service activities that are not otherwise reimbursable through Medi-Cal. While some communities that have developed the Child and Family Team and Intensive Home-Based Services models have blended various funding streams, permitting maximum flexibility, statewide regulations will require that Los Angeles County employ a braiding strategy. For example, EPSDT funded services must be consistent with the limitations and requirements of the Rehabilitation Option used by DMH and its contract providers.

At a minimum, EPSDT, Mental Health Services Act, and the Multiagency Community Pool (MCP) are potential revenue streams that can be considered. In this approach, we could employ a model similar to that previously used in the Los Angeles County System of Care Program wherein the provider agency relied largely on EPSDT for the funding of services with access to flex funds for costs not covered by EPSDT. If this option were employed, the County would in some ways be creating yet another program. This model might be more consistent with a DMH-led approach.

Staffing

The proposed Countywide Care Coordination Unit and the Integrated Behavioral Health Management Leadership Team will require staffing from both DMH and DCFS and considerable support from departmental information systems divisions. It will be important to review available staffing within the Corrective Action Plan that can be deployed in service to these operations as well as re-deployment of other staff within the two departments.

Contracting

It is proposed that Child and Family Teams and Intensive Home-Based Services be contracted to Department of Mental Health contract providers. Initially, it would seem prudent to rely upon those contract providers that have experience with similar intensive programs such as Wraparound, Children’s System of Care, Full Service Partnerships, and the Intensive In-Home Mental Health Services Programs (MST, MTFC, and CCSP). It will be important to streamline the solicitation process as much as possible in order to facilitate the implementation of these programs. One possibility would be to identify a contract provider in each Service Area to provide both Intensive In-Home Services and Child and Family Teams. Option One (above in Funding) would appear to favor the amending of existing Children System of Care contracts.

Training

Significant training, both initially and supported through ongoing coaching and mentoring of staff, will be required to implement and sustain these efforts with fidelity to the Los Angeles Vision, practice principles, and day-to-day practice standards. All new DCFS and DMH staff, as part of their initial training would be oriented to the vision and practice principles, so IHBS is not viewed as another program, but as the driving philosophy. Training options include contacting with the University of California at Davis, the Los Angeles Wraparound Consortium, the California Institute for Mental Health, the Community Services and Supports Program (Phoenix), and members of the National Wraparound Initiative.

Attachments (To Be Developed)

Attachment One

Child and Family Team Activities and Associated Procedure Codes

|Child and Family Team Activities |Associated Procedure Codes |

|1. Engagement and Team Preparation |To be developed |

| | |

| | |

| | |

|Initial Plan Development | |

| | |

| | |

| | |

|Implementation | |

| | |

| | |

| | |

|Transition | |

| | |

| | |

| | |

| | |

| | |

Attachment Two

Child and Adolescent Needs and Strengths (CANS) Tool

Instructions on use of CANS tool

CANS Tool

Attachment Three

Wraparound Fidelity Index 4.0

Attachment Four

Child and Family Team Process Flowchart

Attachment Five

Intensive Home-Bases Services Plan of Care

Attachment Six

Informal Services Tracking Form

Attachment Seven

Description of the Development of the Child and Family Team in Los Angeles County

In 2002, a class action lawsuit (Katie A.) was filed against the State of California and the County of Los Angeles alleging that children in contact with the County’s foster care system were not receiving the mental health services to which they were entitled. In July 2003, the County entered into a settlement agreement resolving the County-portion of the lawsuit.

Under the terms of the settlement agreement, the County is obligated to make a number of systemic improvements to better serve children with mental health needs. Specifically, the County must ensure that class members:

a) Promptly receive necessary individualized mental health services in their own home, a family setting, or the most homelike setting appropriate to their needs;

b) Receive care and services needed to prevent removal from their families or dependency or, when removal cannot be avoided, to facilitate reunification, and to meet their needs for safety, permanence, and stability;

c) Be afforded stability in their placements, whenever possible; and

d) Receive care and services consistent with good child welfare and mental health practice and the requirements of law.

The settlement agreement defines class members as all children who:

a) Are in the custody of the Los Angeles County Department of Children and Family Services (DCFS) in foster care or who are at imminent risk of foster care placement by the Department; and

b) Are eligible for services under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program;

c) Have a mental illness or condition that is documented or, had an assessment been completed, could have been documented;

d) Need individualized mental health services to treat or ameliorate their illness or condition.

The settlement agreement also established an Advisory Panel (Panel) to assist the County in developing plans for meeting the obligations of the settlement agreement and to report to the Court on the County’s progress in doing so. On August 16, 2005, the Advisory Panel issued its Fifth Report concluding that the County had not developed a sufficient plan to meet the needs of the plaintiff class and was not meeting the obligations of the settlement agreement.

In response to this finding, the County developed the County Plan which was approved by the Board of Supervisors on October 11, 2005.

The County Plan calls for a number of systemic improvements to better meet the mental health needs of the plaintiff class. These improvements include expansion of the Medical Hubs, standardized mental health screenings for all children entering foster care, the co-location of mental health staff in DCFS offices, and increases in the County’s capacity to provide intensive in-home mental health services.

The County Plan will be implemented in two phases: Phase One will cover Service Areas 1, 6 and 7; and Phase Two will cover the remainder of the County.

In November 2006, the Court in Katie A. ordered the County to make a number of modifications to the County Plan. In response, the County Plan was modified in accordance with the Court order and approved by the Board of Supervisors in August of 2007. These modifications include the addition of systems for the screening and provision of mental health services to at risk population, greater expansion of intensive in-home mental health services including Wraparound and Treatment Foster Care services, systems to more quickly transition children out of congregate care settings, and systems to better monitor outcomes children are achieving.

Since that time the departments have engaged in a strategic planning process with Panel members and plaintiff attorneys to conceptualize the development of a child and family team process and associated intensive in home services program that would serve class members in a manner consistent with the terms of the Settlement Agreement. Following this strategic planning process, a Child and Family Team Workgroup was formed consisting of staff from the Department of Mental Health, the Department of Children and Family Services, contract mental health providers, Panel members, and plaintiff attorneys to design the elements of a child and family team process and intensive in home services model and develop and implementation plan for these services. The workgroup met on December 20th, January 11th and January 23rd (need to add additional dates here). Additionally, the co-conveners of the workgroup met with Department Directors and Executive Management staff to discuss several overarching issues related to the plan.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download