2.  Overview of Access and Service Navigation

 

          i.        Access

 

The role of CTN Access is to ensure that children with special needs and their families are given accurate information and linked with appropriate services and supports.  The common electronic client record is initiated at Access and supports information sharing, service integration, the development of a Single Plan of Care, and the monitoring of service system gaps and trends. 

 

CTN Access is hosted by the Community Care Access Centre of York Region.  CCAC Access case managers provide service navigation to families and professionals calling the CTN toll free number. Assistance to families is provided seven days a week from 8:30 am to 8:30 pm.  CTN Access also provides a general information function through Information and Referral (I and R).  Families calling for general information about such things as childcare, library services, recreational or community programs, are assisted by experienced I and R staff.

 

        ii.        Service Navigation

 

The Service Navigator provides the initial contact for the family and after completing a multi-domain interview assists the family to access the appropriate services, supports, and information by linking them with the appropriate service agency or, in the case of a child with multiple needs, linking them with an appropriate service coordinator.

 

The Service Navigator: 

§         engages the family with the children’s service system

§         responds to the child and family’s needs in a respectful manner consistent with the principles of family centered care

§         is knowledgeable about available services and supports

§         is respectful of other service providers and agencies and works in a collaborative way to ensure the child and family receive the required services

§         develops the preliminary plan with the family in accordance with the family’s concerns and visions 

§         assists the family to understand the CTN model and the range of services available

§         protects the child and family’s privacy

§         is transparent in all communications

§         is sensitive to diversity and works to support the family’s religious and cultural practices

§         is flexible and individualizes care to every child and family

§         is readily able to identify child and family risk factors and understands duty to report obligations

§         transfers care to other providers in such a way as to instill confidence in the process and in the Children’s Treatment Network

 

CTN Access maintains responsibility for the client until such time as an appropriate service coordinator or service is available.  At times this may involve several calls with the family and the network of agency providers in order to determine the most appropriate agency to meet the long term needs of the child and family.

 

When a child’s needs can be met by a single agency and service coordination is not required.  Information is shared and the client is transferred to the children’s service agency to provide the necessary assessment and intervention. 

 

     iii.        Guiding Principles for Access

 

The following principles guide the development of CTN’s Access Process

 

•         From a Family Perspective

–        Single call, once

–        Holistic

–        Timely and accurate response

–        Prioritize, and provide options/choice

–        Obtain right services

 

•         From  a System  Perspective

–        System information and trending capability

–        Transparent decision-making/prioritizing

–        Equitable

–        Responsive to diversity

–        Flexible

–        Respectful of privacy

 

     iv.        Access Process

 

Caller calls 1-866 toll free Number

 

Call is received by Reception at CCAC York Region.

Receptionist answers “Hello, Children’s Treatment Network, how may I help you?”

 

If family or professional indicates a service need, call is forwarded to Service Navigation.  (If call is general in nature call is forwarded to Information and Referral)

 

Initial Demographic information is taken and entered into electronic client record, client file is initiated

 

Service Navigator (SN) contacts the family and explains the CTN model of service integration, completes the demographics, and begins the CTN Child and Family Interview (CFI).  The SN then proceeds following the steps outlined below in accordance with the situation.

 

1.  If client is New to services:

• SN completes CFI
• Asks family to forward any relevant reports
• SN identifies and discusses most appropriate service or service coordination agency with family
• SN obtains verbal consent and documents consent was provided
• SN forwards the demographic information and the Child and Family Interview by fax or if connectivity is available uses email to alert the agency that a new client has been transferred and that they should view the client’s information in the electronic client record. 
• Reports and referral information are scanned into electronic client record and filed as they are received by the SN.  The SN alerts the agency that new information is available or faxes the relevant documents to the children’s service agency.
• Agency Intake reviews information in the electronic client record and assigns appropriate service coordinator or service provider

 

2.  If client is already receiving Services from a Network Partner:

• SN completes relevant parts of the CFI and identifies any new needs/concerns with the family
• SN obtains verbal consent to forward information to the service coordinator or service provider involved and documents that consent was provided.
• SN forwards the CFI by fax or if connectivity is available uses email to alert the agency that there is new information about the client and that they can view the client’s information in the electronic client.
• Any reports and referral information received by the SN is scanned into the electronic client record.  The agency is notified about the new information. 

 

3.  If client is no longer receiving active services from a Network partner but had had information entered into the electronic client record in the past:

• SN confirms client’s current demographic information with the client’s previous information stored in the electronic client record.  A new file is not initiated. 
• SN discusses reason for call and documents in the electronic client record the family’s new concerns and current needs 
• If client has not received services in the past two years SN completes a new CFI in order to identify any new needs or concerns. 
• SN identifies and discusses most appropriate service or service coordination agency with family
• SN updates consent
• SN forwards the demographic information and the CFI by fax or if connectivity is available uses email to alert the agency that a client has been transferred and that they should view the client’s information in the electronic client record. 
• Reports and referral information are scanned into electronic client record and filed as they are received by the SN.  The SN alerts the agency that new information is available or faxes the relevant documents to the children’s service agency
• Agency Intake reviews information in the electronic client record and assigns appropriate service coordinator or service provider

 

 

 

   vii.        Service Description for CTN Access

 

Purpose

The Access function for CTN services serves as a coordinated mechanism to screen clients as comprehensively as possible, and provide service navigation based on the needs of the child and family, so that the right resources and services can be delivered and coordinated as quickly as possible and as close to home as possible. 

 

Functions

1.                  Service Inquiry

§         Responding to inquiries from families, service providers and others with a view to determining appropriate next steps which might include screening for CTN services; and/or other services.

 

2.                  Referral

§         Screening for eligibility to children’s services.

§         Preparation of unique electronic client record.

 

3.                  Intake Interview

§         Conducting an initial needs assessment, including a scan of existing information, for purposes of transferring the child/family to the right configuration of resources to meet their priority needs. This information may go to a service coordinator to establish a Child & Family Team, to network partner agencies or to organizations external to CTN.

 

4.                  System Navigation

§         Assisting client/family to coordinate resources.

§         Providing short term resource support for families who are awaiting referral to CTN child and family team for service coordination.

§         Assisting client and family to navigate the children’s service system and locate resources and services as appropriate while waiting for longer term services and supports, including service coordination.

 

5.                  Transfer Client/Family to Service Delivery Team

§         Ensuring timely and smooth transfer for ongoing service delivery.

 

6.                  Electronic Client Record Management

§         Initiating the electronic client record in the CTN clinical software application for all clients following initiation of a service request. Initially, PMI will provide a client file until the CTN clinical software application is available.

§         Obtaining records from other service providers and scanning these into the electronic file, as needed for service navigation.

§         Auditing for incomplete, inaccurate, or missing information from the Access and service navigation process

§         Closing the client file where appropriate.

 

 

 

7.                  Collect, manage, and provide system-wide service information

§         Providing utilization reports on a system wide and regional basis to assist CTN leadership manage resources and wait lists.  

 

Role of the Service Navigator

The CCAC will employ staff as service navigators who will work closely with the CTN Access Director (initially Project Manager for Access).

The Service Navigator is the primary contact at Access for the client/family and provides assistance connecting the client/family to appropriate resources including service coordination.  In this role, the Service Navigator:

• responds to initial service inquiry
• screens for eligibility and when not eligible directs inquiries to most appropriate agency
• if eligible, starts electronic file with consent, records demographic information, and completes referral to determine next steps
• completes the Child and Family Interview (CFI) to determine need and identify risk,  and set priorities using existing tools
• identifies agency to assume service coordination and makes referral on behalf of family
• Assists the family to understand the range of services available through the children’s service systems in Simcoe and York
• collects information from previous assessments and service providers with consents to build electronic client record
• obtains consent to share information with the Service Coordinator and the child/family team
• may provide short term support while awaiting  service coordination to be in place which includes development of an initial  support  plan with the child and family and providing relevant information to the child and family in the interim

• advocates on the child and family’s behalf
• refers to the local team facilitator to assist in determining the most suitable service coordinator and participants on the child and family team if no service coordinator identified
• acts as the continued contact for the client/family local team around Access issues
• ensures that Electronic Client Record data is accurate, current and comprehensive
• assists the CTN management team in data management and analysis

 

Skills

• Familiarity with the children’s service system including special need resources
• Excellent customer service skills
• Excellent interviewing and assessment skills
• Excellent negotiation or mediation skills
• Problem solver, good judgement
• Excellent oral and written communication skills
• Knowledge of relevant legislation such as Child & Family Service Act (CFSA)
• Takes initiative and can work as a member of a team as well as independently
• Service coordination, case resolution and case management experience is an asset
• Appreciation for multiple cultures and languages
• Proficient with information service systems