Comprehensive Care Planning
with Youth & Families in RBS
An overview & walk-through of a
Comprehensive Care Planning
Template
Martha Kaufman & Geri Wilson
Learning Objectives
• To understand the benefits of engaging families in
comprehensive care planning process.
• To learn how to develop a comprehensive care plan and track
progress throughout a family/youth’s enrollment in RBS.
• To practice using a case scenario to illustrate how a family’s
strengths, needs and cultural perspective informs the
priorities, interventions and outcomes of family/youth
enrolled in RBS.
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A Functional Best Practice Framework
•
•
•
•
•
•
•
•
•
Child, Youth & Family Voice & Choice
Practicality & Relevance
Outcomes Driven
Strengths-based, Needs-responsive
Right Time, Right Place, Right Kind of Care
Continuity & Portability
Coordinated & Comprehensive
Unified Efforts Across Systems & Locations
Adherence to Mandates
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Service System Benefits
• Takes a step up to unify efforts vs. trying to alter multiple
long-standing documentation mandates
• Promotes coordination in planning & implementation – 1
family/1team/1plan
• Establishes a snap-shot of the big picture, without losing the
details (“I can finally tell what’s going on without slogging
through 50 pages!” MM, District Court Judge)
• Documentation that promotes adherence to best practices in
planning & implementation
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Child/Youth & Family Benefits
• “Finally, I feel like my daughter & our family have our own plan! It
belongs to us and not an agency, and helps us feel like we’re in charge
of our lives.” (TD , parent)
• “I understand this – it has my own words in it.” (JS, youth)
• “I can take this plan with me to help explain what we’re trying to do to
help our son. It has been hard to get some professionals to listen to
me as a parent. Now we have a plan and a team that backs us up.” (DB
& JB, parents)
• “What I like is that all the agencies that work with my kids now work
together through one team and one plan. No more different plans that
tell us different things. I used to worry about missing something and
getting in trouble about it. I’ve got enough worries.” (ASR, parent)
• “I can show our plan to anyone I want to and it actually makes sense!
It’s like our snapshot of what we’re working on and how we’re getting
there, without all the mumbo jumbo.” (CJ, parent)
• “My husband and I can see a difference now that our team uses the
Unified Plan to help us help our teenager. We’re all more on the same
page and people are actually helping us work on OUR priorities.” (DP,
LP, parents)
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How is it different?
One Unified
& Coordinated
Comprehensive
Care Plan
Mental
Health
Child
Welfare
Education
Courts
Juvenile
Probation
RBS
Community
Supports
Separate
Plans
& Orders
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Child
Welfare
Mental
Health
Juvenile
Probation
Courts
Community
Supports
Education
RBS
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The Comprehensive Care Plan
• Helps the child/youth & family & their Care Team create one
overarching plan that coordinates efforts across agency &
organizational boundaries
• Does not replace, but integrates, agency-specific mandated
plans (CW, MH, etc) into one unified family-centered plan
• Uses a Life Domain framework to identify priorities,
strengths, needs & a plan of action to help provide help when,
where & how its needed through RBS
• Defines & coordinates the work of the Care Team
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Using the CCP
Who completes it?
When?
The individuals who lead the
• Upon enrollment in RBS as
child/youth & family Care Team
take primary responsibility for
facilitating (& documenting) the
completion of the CCP:
• with full participation of the
child/youth & family and
part of the Care Team
development process
• At each Care Team meeting
• Whenever the CCP needs to
be reviewed and/or changed
• their key stakeholders/Care
Team members whose help is
needed by the child or youth &
family to help achieve their
consistent with evolving
goals, strengths, & needs of
the child or youth & family
desired outcomes
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How is it completed?
Youth/Family, Stakeholders, & CT Leaders work together, building on
information shared in the Engagement Process: Strengths & Needs
Conversation, Assessment information (e.g., CANS Actionable Items,
CAFAS), & the history of care – what worked & what didn’t
• Initiate a Family-Centered exploration of the child/youth & family’s :
Stated Goals, Strengths & Skills, Unmet Needs & Driving Forces
• Identify the top 3-4 Life Domain priorities with the child/youth
& family (areas of their lives where actions will be focused), such as:
•A place to live
•Getting along as a family
•Taking care of physical health needs
•Taking care of behavioral health needs
•Participating in cultural & spiritual traditions
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•Safety
•Being part of the community
•Doing well in school &/or work
•Having friends
•Having fun
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How is it completed?
• Within each priority LD, identify with the child/youth & family, Care
Team members:
• The key goals of the child/youth & family right now (as stated by the
family) based on their vision of how things can be different in the future
• Their strengths & skills
• Their unmet needs & driving forces behind disruptions that stand in the
way of achieving their goals
• Their hopes & desires about what they want to accomplish in RBS
• Action steps that are agreed upon (utilizing strengths/skills to meet needs
& achieve goals)
• What could go wrong, actions to address, & a Plan B (Crisis P&C Plan)
• (CT Facilitators) document all on the CCP, attach relevant agencyspecific plans
• Have all Care Team member sign, & provide them copies
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The CCP Planning & Implementation Process
Youth/Family
referred for
intervention
Engagement
Process
CM/Worker
& Family
Comprehensive
Assessment
RBS Comprehensive
Planning Process (within 30
days of enrollment)
•Youth/Family
• Key Stakeholders
• RBS Care Team Leader & Parent
Partner
Strengths & Needs
Conversation
Assessment
(CANS, CAFAS)
Explore/Select Best
Intervention & Setting:
• Family-Based Support & Services (@ Home)
• Family-Based Services (Out-of-Home)
• Residentially-Based Services
• Locked Detention
Team Decision
Meeting
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RBS Enrollment
Match Youth/Family
Strengths & Needs with
RBS Provider
Initiate the Care Team &
Complete the CCP
Review S& N Conversation,
Assessment(s), History of Care (what
worked/what didn’t work, &
Begin Family-Centered Exploration of
Youth/Family’s:
 Goals ( their vision of how they want
things to be different in their lives)
 Strengths & skills
 Critical unmet needs that are the driving
forces behind disruptions that have
occurred in their family relationships
 Hopes & desires about what they want to
RBS Coalitionthrough
– MCKaufman
& GWilson
accomplish
their RBS
participation
Initiate the Care Team &
Complete the CCP (cont’d)
Within the Youth/Family’s top 3-4
Life Domain Priorities:
•Youth/Family-Stated Goals
•Strengths/Skills
•Unmet Needs/Driving Forces
•Actions to be Taken
•Crisis Prev & Care Component
(Reference & attach specific
agency service plans/orders)
The CCP defines &
coordinates the work of
the Care Team
The CCP is reviewed at each
Care Team meeting
(monthly/more often as
needed) , using the CCP
Progress & Tracking Form
The Youth/Family & members
of their Care Team change
the CCP consistent with their
evolving goals, strengths &
needs
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LIFE AREA/DOMAIN PRIORITY #1:
What are the Child/Youth
& Family’s Stated *
Goals?
Short Term:
Which Strengths & Skills
will help meet these goals?
Child/Youth
Family
What unmet
Needs or Concerns** stand
in the way of meeting
these goals?
Child/Youth
What Actions need to be taken
to meet these goals?
ACTION
BY WHOM
WHEN
Family
Long Term (6-18 mo):
Transition (18 mo. +)
Note other documents that provide further detail (CWCP, IEP, etc.) here & attach. RELATED DOCUMENT(S):
COMMENTS:
* Goal = what it would look like to be doing okay in this domain of the child/youth & family's life, expressed from their perspective, in their words &
reflecting their culture & preferences.
** This requires understanding the driving forces behind disruptions
in relationships
&&
theGWilson
behaviors associated with those behaviors and/or events.
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Crisis Prev & Care Component
* Patricia Miles (2007). Crisis Plans: Setting the Expectation for Unconditional Care
Tips On Crisis Planning*
• Be sure to ask the child/youth & family what could go wrong during the
implementation of the entire CCP. This is a first step in developing or
revising the Crisis Prevention & Care component. The child or youth &
family know best what can go wrong.
• Always build a crisis component that "triages" for different levels of
intensity & severity of crisis events (prioritizing actions according to the
seriousness of the condition or events). Small crises do not require the
same response or reaction as more serious crises demand.
• Build the crisis component for a 24-hour response. Crises seldom occur
when it is convenient.
• Always create a ‘Plan B’ in case the people who were supposed to provide
backup or intervention are not available when the crisis occurs, etc.
• Always double check with the child or youth & family each time the crisis
component is updated - Will it work?
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Crisis Prev & Care Component*
CRISIS PREVENTION & CARE COMPONENT
What crises are
most likely to
occur?
What actions will be
taken to prevent/avoid
the crisis?
What actions will be
taken if the crisis
occurs?
Who will take
the actions?
What is PLAN B?
* Patricia Miles (2007). Crisis Plans: Setting the Expectation for Unconditional Care
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Tracking Progress in the CCP
The CCP Progress & Tracking Form is a tool to help children or
youth & families participating in Residentially Based
Services (RBS), along with members of their care team (e.g.,
Family Support Team) assess how things are progressing,
what’s working & what’s not working in their
Comprehensive Care Plan (CCP).
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CCP Progress & Tracking Form
Who completes it?
• The individuals responsible for facilitating the Care Team,
together with the child/youth & family & key stakeholders
whose help is needed to help them achieve their desired
goals.
When should it be used?
• At every Care Team meeting
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How is it Completed?
• The CT Facilitators review each Life Domain priority on the
CCP, related goals & action steps with the child or youth &
family & other members of their Care Team to assess how well
implementation of the CCP is going
• Through a consensus process, indicate on the Tracking Form
how the Team would rate the progress in meeting each goal
within the Life Domain priority, using the 1-10 scale, with 1
indicating ‘not working’ and 10 representing ‘total success’ .
The care team should strive to agree upon a rating that is “good
enough” to progress to a next goal, e.g., a “7”
• Always include a rating for the Crisis Care & Prevention
Component
• Indicate the time frames that are being measured at the bottom of
the Tracking Form chart, e.g., monthly
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How is it Completed?
• Once a few months of data are collected in terms of progress made, the
Care Team can create a graph to illustrate progress of goals over time
• The Comprehensive Care Plan & the Tracking Form are interrelated.
When it is time to focus on new goals and/or to select new Life Domain
Priorities (according to the results of the Tracking Form), utilize the
CCP template to reflect changes as needed to respond to the child’s or
youth’s & family’s changing strengths & needs as they progress toward
their stated goals
• Indicate whether changes were made to the Comprehensive Care Plan
as a result of the progress review & the date of the CCP that reflects
these changes, if made
• Indicate the date, time & location of the next Care Team meeting
• Have every Care Team member sign the Tracking Form & provide
them with copies
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CCP Progress & Tracking Grid*
Life Domain Priority #1:
Youth/Family Goal:
Action Steps Taken:
Measure: Indicate below which number represents how well are things progressing to meet this Goal
Total success
10
9
8
Well enough
7
6
5
4
3
2
Not at all
Time Intervals:
1
A
B
C
D
E
F
G
H
I
* John Franz, Getting from Hello to Help
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Will & His Family
Sue Jordan is 32 years old, married to Joe Jordan & the mother of three
children, Britta (4), John (2), & Will (13). Will was removed from his
parent’s care at age 4; after it was found out that he was being left alone for
long periods of time while his parents went out with friends. Since that time,
Will has been in multiple foster homes & residential treatment centers. Sue &
Joe continue to struggle with the guilt of neglecting Will during their “wild
years” & have hated to see him bouncing around in placements. At the same
time their two young children both have disabilities, & while things are far
from perfect, they are functioning as a family & doing okay.
Sue & Joe are both avid readers & take pride in the work they have done to
understand how to meet Britta’s & John’s special needs. They have also tried
to stay in Will’s life the best they can, remembering to send him birthday &
holiday gifts that encourage his talent in drawing & support his interests in
music & computers. Will treasures these gifts & makes a special place in his
room everywhere he lives to keep them in view. He also carries a backpack
with him that has the treasures he hopes to put out some day when he has his
own room in his own house. He is trying not to give up on that dream, but
wonders if there is still a place for him in his family.
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Will & His Family
Sue is finally pursuing one of her life dreams, going after a Med Tech degree at
the local college. Joe, who had lived on the road playing for a minor league ball
team (pursuing his dream to play in the major leagues), took a job in town a little
over a year ago to help more with the kids so that Sue could attend classes.
However, Joe was laid off three months ago. The family is now having a tough
time making ends meet financially, because Joe has not been able to find another
job.
Sue & Joe are just not sure that they can take care of Will, especially given their
current financial situation & the behaviors Will has developed. They decided to
try a couple of home visits last month to see how things went. They did not go
well. Will refused to go along with his parents’ instructions & threw violent
tantrums & Sue is worried that he might hurt Britta and John. She called the
police twice because of the tantrums and an action in juvenile court is pending.
Will came back to the residential facility feeling pretty angry & hopeless, telling
staff that he just wants to be emancipated when he is 16, just like his older friend
in the last foster home.
Last week, a staff member from the residential facility phoned Sue & Joe to let
them know about a new option that might help their family, called RBS. It all
sounded pretty complicated, but Sue & Joe agreed to meet with the staff to find
out more.
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Info from Strengths/Needs Chat
Will
• Has begun to make friends in the RTC
• Has a strong connection with a former foster mother & they talk by phone
• Just had a display of his drawings in the cafeteria during Art Week
• Likes to write & is a quick learner, especially when he can use a computer
• Hits first, asks questions later, but will talk it out if given a chance
• Will take what he wants when frustrated
• Was recently diagnosed with Bi-Polar Disorder & is worried about what that means
• Is doing okay in small structured class
Sue
• Is committed to finding a way to balance family & school
• Is willing to keep trying to find a way to keep Will in the family
• Is overwhelmed, gets frustrated
• Has close friends in the neighborhood
• Is involved in her Church
• Wants to become more skilled using the computer for her school work
Joe
• Put his dream aside so Sue could pursue hers & is committed to finding another job
• Is willing to consider options that could help Will be with the family again
• Has friends on the neighborhood soft ball team
• Is worried about money but doesn’t feel like he can show it
• Has a temper, but has learned to step back before he reacts
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Findings from the CANS
Strengths that can be further developed:
• Interpersonal
• Educational
• Talent/Interests
Strengths that must be built:
•
•
•
•
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Family
Relationship/Permanence
Vocational
Well-being
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Findings from the CANS
Mild degree of need or watchful waiting to see if need develops:
•
•
•
•
•
•
•
•
•
•
•
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Family Functioning
School Achievement
Depression/Anxiety
Adjustment to Trauma
Temporal Consistency of Mental Health Problems
Abuse History
Social Behavior
Seriousness of Criminal Behavior
Urgency of Care Management
Supervision
Organization
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Findings from the CANS
Moderate need and need for action:
•
•
•
•
•
•
•
•
•
•
•
•
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Permanency
Psychotic Symptoms
Attention Deficit/Impulse Control
Anger Control
Oppositional Behavior
Violence
Monitoring
Treatment Intensity
Service Permanence
Family Involvement w/Care
Family Knowledge
Family Resources
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Will & Family’s Care Team
Name & Signature
Will Jordan
Will Jordan
Relationship/Agency/Organization
Phone
Email
Myself!!
WillCoLater@ hotmail.com
Will’s mother
SJ [email protected]
Will’s father
[email protected]
Care Team Coordinator
DBennet@RBSconnect. com
Parent Partner
[email protected]
Abby Lowe
Sally Holt
RBS Program Team/Therapist
[email protected]
Sally Holt
Friend & neighbor
[email protected]
Teacher & coach
[email protected]
Will’s former Foster Parent
[email protected]
Juvenile Court Counselor
[email protected]
Child Welfare Case Worker
[email protected]
Sue Jordan
Sue Jordan
Joe Jordan
Joe Jordan
Dan Bennet
Dan Bennet
Cheryl Gates
Cheryl Gates
Abby Lowe
Henry Lamont
Henry Lamont
Edith Mann
Edith Mann
Susan Houston
Susan Houston
Jim Roth
Jim Roth
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LIFE AREA/DOMAIN PRIORITY #1: A place to live & get along with family (Residence, Family, Permanence)
What are the
child/youth &
family’s stated
Goals?
Which Strengths & Skills will
help meet these goals?
What unmet
Needs or Concerns stand
in the way of meeting
these goals?
Short Term:
Child/Youth
Family
Child/Youth
To feel like it’s
really possible to
fit in with my
family & not blow
it by getting upset
(W)
When upset will
talk it out if
given a chance
Is willing to
consider options
that could help
Will be with the
family again
Driving forces –
loneliness, fear of
never finding a
family to love &
be loved by, fear
of abandonment..
Need for hope.
Get to know W
again as a person
& let him know
we love him
(S&J)
Enjoys using
computer, wants
to be close to his
family
Have enough
money to keep our
home & take care
of our children &
meet their special
needs
(S & J)
8/31/2009
ACTION
BY WHOM
WHEN
Family
Assessment &
support via
family visits in
RBS facility
Driving forces fear about ability to
keep the family
together safely;
Guilt about
abandoning W;
Overwhelmed
about parenting.
Need for hope.
Commitment to
finding a way to
balance family
and school (S);
Follow all leads
on job
possibilities (J);
Continue reading
about best ways
to help our
children (J&S)
What Actions need to be taken
to meet these goals?
Joe’s concern that
he won’t be able to
support his family;
Sue’s need to
balance home,
children & school;
Concern about W’s
diagnosis & what it
means he needs
(S&J)
RBS Coalition – MCKaufman & GWilson
Phone support
by W’s former
FP
•Support Will in
writing a selfportrait & about
his dreams for the
future to share
w/Family
Educational
sessions w/family
about W’s dx
Facilitate
connection to new
community
Recession-Proof
Financial
Support program
Dan J/lead,
w/RBS site
team &
Cheryl G.
Saturday
9/12 & 9/26
Edith M.
Weekly,
beginning
9/3
Abby H,
Jim R
(See
attached
CWCP for
further
detail)
•Beginning
9/10
Dan J/lead
w/RBS site
team
9/12
Cheryl G.
9/22
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LIFE AREA/DOMAIN PRIORITY #1: A place to live & get along with family (Residence, Family, Permanence)
What are the
child/youth &
family’s stated
Goals?
Long Term (6-12 mo)
Which Strengths & Skills will
help meet these goals?
Child/Youth
To feel confident as
parents of a teenager
(S&J)
To feel like I can have
my own room in my
own house & stop
worrying about
moving all the time
(W)
Family
What unmet
Needs or Concerns stand
in the way of meeting
these goals?
Child/Youth
Hx of reaching
out to learn
how to help the
children
Keeps gifts &
cards from
family to go
into his room;
Loves to draw
What Actions need to be taken
to meet these goals?
ACTION
BY WHOM
WHEN
Family
More practical
information about
how to do this
everyday
Confidence that
his room is there
for him and is a
part of him & a
part of the family
home
Facilitate
connection to
Parents of Teens
community group
Dan J &
Cheryl G.
By2/1/10
Support Will in
creating new
drawings for his
room
Redecorate
Will’s room
Sue, Joe,
Sally
By 2/1/10
Will, Sue,
Joe, Sally
Beginning
2/15/09
Transition (18 + mo)
Staying together &
getting along as a
family (W, S, J)
Note other documents that provide further detail (CWCP, IEP, etc.) here & attach. RELATED DOCUMENT(S): Child Welfare Case Plan
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Tracking Progress
Goal: Get to know W again as a person & let him know we love him (S&J)
Action Steps Taken: Assessment & support via family visits in RBS facility; Phone support by W’s former FP
Measure: Indicate below which number represents how well are things progressing to meet this Goal
Total success
Well enough
Not at all
Time Intervals:
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10
9
8
7
6
5
4
3
2
1
.
….
1 mo
2 mo
3 mo
4 mo
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Testing the CCP in Sacramento
• Creates a "standardized" centerpiece for a coordinated care
planning approach for RBS providers and county case
managers
• Provides a solid foundation for family focused, strengthbased, individualized care plan development
• Ensures the case planning process is inclusive, overarching
and coordinates the efforts and requirements of all key
stakeholders
• Serves as a great communication tool and provides the
opportunity for the Care Team to create a shared vision for
care and outcomes
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