4.  Overview of Service Delivery

 

i.              Service Description for Service Coordination

 

The goal of service coordination is to optimize family functioning and promote healthy child development by providing quality, integrated services in the most efficient, effective manner to families.

 

Definition

Service coordination is a family centered process that enables families, service providers and informal supports to plan, coordinate and monitor a comprehensive individualized Single Plan of Care.  It facilitates the achievement and maintenance of a quality of life consistent with the family’s values, priorities, strengths and preferences.

 

Service Coordination takes a lead role in establishing links among service providers and informal supports, across all systems:  health, education, social services, financial resources, recreation, transportation, housing, etc. and guides the overall implementation of the individual Single Plan of Care, in consultation with the other team members.  Families can be their own service coordinator, they can share that role with another team member, or they can request that a team member be the service coordinator. 

 

Principles of Service Coordination:

1.    Single point of contact, helping families to coordinate care and continuity across systems and time. If there is more than one coordinator, one will be designated lead.

2.    Promotes and safeguards interest and well being of children and families.

3.    Respects the family’s dignity, rights, values, priorities and preferences.

4.    Empowers families in determining their needs, vision, goals and the resources they require.

5.    Supports effective, collaborative and respectful communication with all individuals involved.

6.    Is sensitive to differences in culture, background, religion, and physical and cognitive development.

7.    Supports a focus on existing community-based services, recognizing the least restrictive alternatives, minimal intervention, and the use of informal supports.

8.    Supports a focus on a holistic approach that recognizes the uniqueness of each individual’s needs and strengths.

9.    Supports accessibility to a wide range of community supports, assuring children and families are offered the services they require.

10. Provides continuity, consistency and coordination of supports across all service sectors.

11. Ensures confidentiality and obtains repetitive informed consents from the family in accordance with respective agency policies.

12. Complies with the Duty to Report, in Section 72 of the Child & Family Services Act.

13. Minimizes duplication of assessments and services.

14. Embraces a practical, evidence-based approach to the delivery of health and social services that is responsive to changes, to ensure quality care and outcomes.

15. Ensures that the service coordinator is free of conflict of interest.

 

Service Coordination Processes

 

Service Navigation occurs at CTN Access when service navigators complete the initial intake interview and ensure the family of children with multiple needs is connected appropriately to a service coordinator in the appropriate local team.  Service Coordination begins when two or more service providers are or need to be involved with an individual or family to develop and coordinate a single plan of care.  The first service coordinator receiving the family from Access will assume the temporary service coordination role, and will begin the Initial Plan for Assessments and Services (IPAS), until an ongoing service coordinator is selected.  Roles for the temporary and ongoing service coordinator are contained within this document.

 

The role of Service Coordination is the planning and coordination of services. The intensity and type of service coordination varies based on the child and family’s characteristics and changes with variable needs, within the context of their environment. Responsibility for service coordination may be shared with the family and other service partners, but a lead will always be determined. This responsibility may include any or all of the following elements:

 

1.    Identification in Access:  Identification and engagement takes place after the initial screening or referral in Access.  When sufficient eligibility is determined, the client record will be opened.  Information sharing, obtaining consent and establishing a relationship occur at the time of engagement, and during the bridging between service navigators in Access, and service coordination at the local teams.

 

2.    Assessment:  An overview of the family’s physical and emotional health, values, cognitive status, functional status, coping abilities, resources and environmental conditions occurs for planning purposes.   This overview provides information, from which the family’s strengths, supports, resources, needs, limitations are determined.  The Service Coordinator works with the family to identify and prioritize their visions for the future for their child and family.  Assessment of risks and identification of crisis intervention and prevention strategies are key considerations in the assessment function.  The initial assessment is documented in the Initial Plan of Assessment and Services (IPAS).

 

3.    Accessing Resources & Linking:   When the visions have been determined, professional and informal resources, including family, friends and community are considered.  The service coordinator sets in motion the network of service providers who will work together with the family as a child and family team during the assessment process and for treatment where applicable.  This network will also include CTN Specialty Services and Tertiary Resources.  Families are helped to recognize their strengths and supports thus empowering them to be an active partner in the linking of resources.

 

4.    Goal Setting, Service Planning and Transitions:  The child and family team’s assessments provide the framework for the determination of the Single Plan of Care (SPOC).  Service Coordination involves conferencing with the team to align all goals with the family’s prioritized visions.  As much as possible the service coordinator and team work together to develop common, multidisciplinary goals and activities to create a manageable plan for the family.  The planning process will be iterative, to accommodate changes in needs, and particularly to prepare for successful transitions at key stages of development.

 

5.    Service Implementation & Coordination:   Implementation of the Single Plan of Care is facilitated by the service coordinator together with the family.  Conferencing with service providers, implementing the Single Plan of Care, and mobilizing the family’s supports are essential.  Communication, coordination, and prevention of duplication are pivotal to the efficiency of the Plan implementation and achievement of outcomes.  Maintenance of systematic records supports ongoing assessment and monitoring throughout.  Families may wish to act as the service coordinator or they may choose the person from an agency most involved to be the service coordinator; however, responsibility for maintaining the electronic client record must be assigned.  It is the primary responsibility of the service coordinator to ensure a smooth transition between service coordinators, particularly at transition times, or when a large number of team members are changing.

 

6.    Monitoring & Reassessment:  The service coordinator will monitor the Single Plan of Care with the family.  The plan is reviewed and adjusted in response to changes in the child and/or family’s needs and strengths.  For active children, team meetings occur at a minimum of twice a year at predetermined times or at crisis or transition points depending on a family’s needs.

 

7.    Advocacy:   Advocacy has two facets.  It includes intervention on behalf of the client to obtain current resources in partnership with family and family’s consent.  Advocacy also may seek change in the system or add resources.  Advocating for the client includes the responsibility to identify and communicate the gaps in the system.  Encouraging community development, outcomes based on research, participation in social action for program refinement, and ongoing education may be involved.

 

8.    Supportive Counselling:  The service coordinator would provide support, encouragement, counselling and feedback to enable families to realize their visions and facilitate problem solving.  Access of the Social Work specialty resource or other network counselling providers may be required as appropriate and would be facilitated by the service coordinator.

 

9.    Evaluation & Outcomes:  A planned evaluation of the process and follow-up in relation to the client’s satisfaction, goal attainment and Single Plan of Care efficiency is done.  The service coordinator should consider evaluation of the client service and the overall system to help identify and report any gaps or barriers.

 

10. Discharge, Transition Planning & Disengagement:  Collaboration and negotiation occur among the families, the service providers, informal supports and service coordinator, to determine the needs for further services based on the priority needs/goals met.  When service needs are expected to be lifelong, this includes significant transition planning with other sectors, including adult systems, to be initiated when the child is 14 years old. Some families may require a separate discharge meeting to review progress, identify any unresolved issues, and make recommendations and closure. 

 

When only one service provider is required for support, the family can be discharged from the service coordination process.

 

Procedures:

 

1.    Identification in Access:

• Service Navigator determines if there is a service coordinator in place and makes contact with the service coordinator to highlight the family’s concerns and requests
• ACCESS identifies the priority for Service Coordination, thru levels 1 – 4; level 5 = Case Coordination; this level of service coordination support would only be referred from child and family teams
• ACCESS will use the following guidelines to transfer the families for service coordination.  It is recognized that all service coordination agencies should have the capability to assume any child, but that each agency has expertise with certain areas of need:
  

-- Early Intervention Programs -- preschoolers

-- CCAC -- medically fragile with instability

-- Developmental Services Agency – school aged children with cognitive concerns       

-- School Boards -- access to school curriculum issues

-- Mental Health Agencies – mental health issues affecting the child and/or family; child protection issues

• ACCESS would identify if the family will require interpretation services for Service Coordination
• Service Coordination agency accepts referral and assigns Service Coordinator before Service Navigator transfers client
• All documentation collected at ACCESS is transferred to the Service Coordinator

 

2.    Assessment: 

• The service coordinator is contact with the family either over the phone, in person, or with an Initial Service Planning Team to review the information collected at ACCESS
• The service coordinator explains the assessment process and the role of the service coordinator to the family
• Family is offered the choice of coordinating services on own or with the support of the service coordinator
• Initial vision statements are developed by the family with assistance from the service coordinator where required
• Through analysis of these visions, the family and service coordinator identify who else needs to be involved in the Child and Family’s Single Plan of Care
• The service coordinator has the family sign consents to include the identified network provider agencies in to the circle of care; for sharing information and planning purposes
• The service coordinator conducts their own assessment around supports that may be required for social services, finances, recreation, etc. and aligns them with the family visions and makes recommendations.  If these visions are deemed a priority for the family, the service coordinator may develop some short term goals to address these needs.
• If the service coordinator finds they are not the most appropriate service coordinator or does not have the capacity to take on the enhanced service coordinator role, they would negotiate and plan a transfer of care with another service coordinator/service coordinator agency
• Family is provided with a Canchild Family Kit
• All information is documented in the Initial Plan for Assessment and Services

 

3.    Accessing Resources & Linking:  

• The service coordinator contacts the service provider agencies electronically (those that are linked to CTN) to inform them of a need for assessment and provides the family’s Initial Single Plan of Care in which the family visions are documented
• The service coordinator will facilitate the transfer of information from Bloorview Kids Rehabilitation, Sick Kids and other tertiary/specialty medical services through parental consent
• The service coordinator will electronically alert Specialty Services and connect with the Specialty Team Facilitator of a child requiring service when deemed beyond the scope of the local team providers

 

4.    Goal Setting & Service Planning:

• Service Coordinator sets the date, time, location and agenda for the Single Plan of Care meeting and invites appropriate members of the child and family team
• Service Coordinator phones family before Single Plan of Care meetings to determine what family wants to achieve/communicate/learn/share at meeting
• Service Coordinator chairs the Single Plan of Care meeting.  Gathers reports/update information from team members who will not be attending and makes that information available at meeting.

• Service Coordinator ensures that all recommendations identified by the providers align with the family visions
• Service Coordinator ensures that the families priorities are heard
• Service Coordinator may need to work with the family ahead of this meeting to discuss their visions and frame them in such a way that is meaningful to the family and the team
• Service Coordinator challenges the team to develop common activities to address multiple goals
• Service Coordinator is responsible for the documentation and dissemination of the Single Plan of Care

 

5.    Service Implementation & Coordination: 

• The Service Coordinator updates the Single Plan of Care (visions, recommendations, follow-up assignments with who is responsible, SMART goals, timelines)
• Service Coordinator is responsible for engaging other network providers as identified and educating the entire child and family team on the Single Plan of Care
  • Service Coordinator contacts the family either face to face or by phone:
  • To ensure they understood what was said, done, decided,
• To ensure integration/follow through of plans (strategies/techniques) into the home.
• With family agreement, Service Coordinator carries out ongoing implementation of recommendations relative to SC role, e.g., complete funding applications, relay/review therapeutic intervention, equipment use, liaise between non home based service providers and home if required (e.g., school)
• The service coordinator may attend appointments with families when required, particularly when they are responsible for the communication or follow up from these appointments back to the team (e.g. of cases where this may be required may include ESL families, parents with mental health or developmental issues)
• See priority tool for service intensity guidelines

 

6.    Monitoring, Reassessment & Transitions: 

• It is the responsibility of all child and family team members to adhere to the SPOC.  As activities and goals change, the team must be aware of the impact on the overall plan and should take responsibility for calling a Planning Meeting when it is felt that too many changes have occurred and the plan is beginning to feel fragmented.  The Service Coordinator is recognized as the lead in this process.
• Recommended frequency of Single Plan of Care meetings:

                                               i.     Inactive children = mail out/contact in anticipation of key transition points.  Families would be directed to contact ACCESS to be re-interviewed, prioritized and directed to the most appropriate service coordination agency.  The ideal would be if the previously assigned service coordinator could be utilized.

                                             ii.     Active children = dependent on number and frequency of changes to the SPOC.  Level 4 children are likely to require a minimum of 2 SPOCs annually.  SPOC changes are anticipated for the following and would, therefore, likely require a meeting:.

1.    Transition Points

2.    Assessments/reassessments by Specialty or Tertiary Services.                   

 

• If the service coordinator finds they are not the most appropriate service coordinator as the child’s needs and family visions change, they would negotiate and plan a transfer of care with another service coordinator/service coordinator agency

 

7.    Advocacy:

• Client gaps would be addressed with the child and family team; gaps in the child and family team would be identified and the service coordinator would assist the team to engage in new team members from the local team

• Gaps and/or barriers at the local team would be brought to the attention of the Local Team Facilitator to leverage services from another team if possible
• System gaps and/or barriers and possible solutions would be reported to Local Team Facilitators
• Facilitators will bring these issues to the CTN Clinical Directors during their regular team meetings
• CTN Clinical Directors would discuss with individual agencies or the Advisory Forum of York Region or the Simcoe County Coalition for solutions and support

 

8.    Supportive Counselling: 

• Service Coordinators can only offer counselling within their scope of practice.
• Clinical counselling should be arranged by the Service Coordinator thru the CTN Social Work services of a network partner.

 

9.    Evaluation & Outcomes: 

• Service Coordinators will be involved in CTN outcome initiatives, including the research study, parent satisfaction tools, etc.

 

10. Discharge, Transition Planning & Disengagement: 

• To ensure a new service coordinator is assigned and a smooth transition planned when the current service coordinator involvement is ended and the family still requires further services.
• The service coordinator may need to go back to Service Navigation for guidance if their agency is no longer considered the appropriate provider or has the capacity at the given time

 

Identifying a Lead Service Coordinator

 

Rationale

-       evidence suggests that a lead professional is central to the effective delivery of integrated services to children who require support from a number of providers

-       establishing a lead helps to overcome some of the frustrations in dealing with lack of coordination, numerous lengthy meetings, conflicting and confusing advice, not knowing who needs to talk to whom, not being able to identify the right support/right place/ right time

 

Goal 

-       All children who are receiving support from more than one practitioner receive a needed amount of service coordination.  

-       Children who are receiving service coordinator/case management from more than one person will have one practitioner who takes a lead role to ensure that services are coordinated, coherent and achieving intended outcomes.  

 

Core functions of the lead service coordinator:

-       to act as a single point of contact for the child or family

-       to coordinate the delivery of actions agreed by the practitioners involved

-       to reduce overlap and inconsistency in the services received

 

The lead is:

-       selected from among any of the people currently involved

-       should be the practitioner most relevant to the action plan, or who has the most appropriate skills

-       not necessarily the first person to be involved

-       determined as part of the assessment and planning process with the child & family team, and as trust and relationships are established

-       based on criteria established in the local teams to avoid confusion in understanding the roles various members play.

 

Criteria for determining the lead:

-       the predominant needs of the child/family

-       level of trust established with the family

-       the family’s wishes

-       primary or mandatory responsibility in the situation – e.g. CAS

-       the skills/ capacity of the practitioners involved.

 

When a lead service coordinator is no longer needed (e.g. a ‘regular’ EI or CCAC case manager is sufficient to coordinate services), the lead SC role could be terminated/transferred to the regular EI, with flags in place to watch for needs that may intensify again.