A Case of Collaboration Across Systems: The Single Coordinated Case Plan

Francine Feinberg, Psy.D. and Patricia Aniakudo, MSMeta House, Inc.

Acknowledgement goes to the State of Wisconsin, Department of Health and Family Services and the Management Group, Inc. for their support and information.

Using the Single Coordinated Care Plan

(SCCP)

Go to:

www.tmg-wis.comYou will find:

Introduction to the SCCP SCCP Process Guide SCCP Forms and Instructions SCCP Release Forms and Instructions Other information about the history,

performance measurement and local participants.

Handouts

Barriers Core Values Child Welfare Stipulations Rules of Supervision TANF Employment Plan SCCP forms

Systems and their focus

Child Protection – safety and health of children

Substance abuse/mental health – the reduction/cessation of substance abuse and the reduction/cessation of symptoms

TANF – employment and economic independence

Criminal Justice – Public Safety and reducing recidivism

Systems differ in many ways

Goals Expectations and requirements for success Definition of success based on its own

outcomes Funding sources and accountability

requirements

Coordination challenges

While workers may be well trained to understand their own system, they may not have a good understanding of other systems.

Front line staff in each system develop plans for the consumer without consideration to other plans being developed for the same consumer in other systems

There may be little or no sharing of information between systems or it may be left to the consumer to carry information between systems.

Result

Multiple meetings for client; sometimes scheduling conflicts

Requirements to receive same service from multiple providers

Frenetic pace to meet all requirements Client required to do the impossible Failure blamed on client resulting in severe

consequences.

Meet Paula

Homeless – living in a shelter Recently released from prison One child in foster care (age 3) One child with her (age 10) Constantly feels anxious, cries easily, has

difficulty concentrating Substance use disorder – alcohol, cocaine,

heroin

Child Welfare stipulations for reunification

Stay in touch and cooperate with worker, meet with worker weekly to check progress

Have a safe, suitable and stable home Have regular successful visits with your child Call child regularly Complete a psych evaluation Complete programs recommended by evaluation Resolve all criminal charges and cooperate with probation

officer Complete:

AODA program – have negative urine tests Parenting program Nurturing program Anger Management

Have successful extended visits

Rules of Community Supervision

Avoid contact with XX (Father of 3 year old & criminal partner) Complete AODA program and sign consent to release

information to your agent Get a mental health evaluation and follow-through on

recommendations Provide urine for analysis Meet with officer weekly Attend anger management classes Obtain employment Pay restitution, fines and supervision and court fees Obtain safe housing

TANF Employment Plan

Basic Education/GED Hrs/wk: 10 Employment Search Hrs/wk: 15 Ongoing Dr. appts Hrs/wk: 5 Report to worker weekly

Wisconsin INITIATIVE inMilwaukee – State

Partners

Department of Workforce Development Division of Economic Support

Department of Health and Family Services Division of Supportive Living Child and Family Services Health Care Finance

Process to Identify Barriers

Three groupsConsumer perspective

System perspectiveFunding impact

ParticipantsConsumers HMO’sMH/AODA agencies Milw. Cty gov.TANF agencies State gov.Child Welfare Agencies Gen. Comm. Wraparound Milw.

Identified Barriers

Consumers are involved in multiple systems Separate goals Timelines Expectations Lack coordination Communication

Identified Barriers

Systems lack consumer focus viewed as recipients of discrete

services not as whole people viewed as having deficits lack of trust and understanding

between consumers and the systems.

Identified Barriers

The approach sometimes reflects societal stigmas toward people with mental health and substance abuse issues.

Identified Barriers

The assessment and treatment system is not designed to adequately meet the needs of women who have complex mental health and substance abuse issues.

Funding source structure and administration do not support consumer focus and achievement of outcomes.

Transformation of Service Delivery

Develop an integrated service network that assists families in gaining self-sufficiency by building upon their strengths and supporting them through formal and informal service networks.

SYSTEM OUTCOMES Collaboration

across funding streams

Team Approach across systems

Family centered and strengths based plans

Consumer involvement at all levels

Gender and Culturally responsive plans and services

Sustain system change over time

CORE VALUES

Family-Centered Consumer Involvement Builds on Natural and Community Strength-Based Unconditional Care Collaboration Across Systems Team Approach Across Agencies Ensuring Safety Gender/Age/Culturally Responsive Treatment Self-sufficiency Education and Work Focus Belief in Growth, Learning, and Recovery Outcome-oriented

Strength-Based Focus

What does she have - rather than what she does not have

What can she do - rather than what she cannot do

What has she been successful at rather than how she has failed

Assumptions in Strength-Based focus

Everyone has strengths People are experts on themselves Everyone deserves to be treated with

respect and dignity People can make well-informed decisions

when they are supported When people are involved in decisions about

them the outcomes can improve A team is often more capable of creative and

high quality decision making than an individual

The Single Coordinated Care Plan

A team-based, family-centered care planning process to help clients achieve improved outcomes.

Care teams consumer facilitator system representatives friends family other support people

Principles The consumer is central to the process

focuses on the consumer's needs simultaneously addressing the requirements

and mandates of each system

Builds on the consumer's vision and strengths help the consumer meet her needs, as she

defines them all participants work together to help the

consumer meet her needs

Principles Built around natural supports

Systems should fill the gaps

Everyone on the SCCP team is accountable for doing his/her part.

Goal is to help the consumer achieve self-sufficiency in meeting life goals.

Getting Started

Identify who will be at the team meetings Ideal

Many people formal and informal supports Reality

Women with SUD’s often have no family, friends or community support when starting process

Not everyone can come to every meeting from all the systems

Developing the plan

Roles: Facilitator Paula Child Welfare Parole Officer TANF worker AODA counselor Brother

Functional Strengths of Consumers and Team Members

1. Great mother 7. Good work ethic

2. Hard worker 8. Realistic

3. Sensitive 9. Honest

4. Open-minded

5. Learns well

6. Willingness

1. Strong advocates

2. Resources

3. Concern

4. Knowledge of community resources

Consumer Vision

Living my life independently as a single mother

Consumer Name: PaulaLead Facilitator:

Date of Initial SCCP:

Dates of SCCP Revisions:

SINGLE COORDINATED CARE PLAN (SCCP)

1. Consumer Need: Reunite my family

Strategies to Meet Needs: (For each strategy include the following: what, who, where, when, how long,

funding source, and other relevant information)

Updates:(Progress and accomplishments – use dates where applicable)

2. Consumer Need: Become financially self-sufficientStrategies to Meet Needs: (For each strategy include the following: what, who, where, when, how long,

funding source, and other relevant information)

Updates:(Progress and accomplishments – use dates where applicable)

3. Consumer Need: Resolve my legal issuesStrategies to Meet Needs: (For each strategy include the following: what, who, where, when, how long,

funding source, and other relevant information)

Updates:(Progress and accomplishments – use dates where applicable)