The following list identifies a number of skills necessary for Care Coordinators hired within Wraparound Projects. This list of skills can be conceptualized as a tool kit for Care Coordinators who are hired to work alongside positions filled to implement the Wraparound Planning Process and should be helpful for those individuals who are responsible for supervising staff attached to the Wraparound Planning Process. This document is divided into the four phases that the Wraparound Process entails including Engagement, Planning, Implementation and Transition. ENGAGEMENT Description: The engagement phase is focused on the initial stage of Wraparound Planning and encompasses initial team development through face-to-face contact with the Participant s Family as well as either face-to-face or telephone contact with potential Family Team Members. Formal Wraparound Team meetings are not occurring during this phase as the Care Coordinator is gathering perspectives through interview in order to get a sense of family strengths and needs as well as concerns by all involved in the team. This phase typically lasts two (2) weeks. Introduce yourself and explain your role in a way that the family and referring party understands. Explain the team process in a way that makes sense to the family, and encourages the family to want to participate. Talk with families and potential team members of the support system to gather perspectives. Hear the family s story to identify potential team members, needs and strengths. Complete initial assessment of family safety. Provide stabilization resources in crisis situations in order for the team to move towards the next phase of planning. Assist in the development of the family strength summary that describes the family by life domains, and present to the family at the first family team meeting. 1
PLANNING Description: This phase is the plan development phase of Wraparound and requires Participant and Family Team meetings which will include the Participant s Family, CONTRACTOR staff and at least one other party in order to qualify as a planning meeting. That one other party may be the SSW, DPO, or Clinical Therapist. This phase, which should commence at least by the end of the third (3 rd ) week after the referral is made, requires the Participant and Family Team to come together, review family strengths, develop a collaborative Family Team Vision Statement which all team members can buy into, listing needs statements across life areas, prioritizing as a team the most important needs, and crafting interventions and actions to meet the prioritized needs. Review details and data gathered during the engagement phase to help bring the team together. Assemble and schedule a Family Team Meeting at a place that is convenient for the family. At the meeting, explain the process used at team meetings, the purpose of the strengths orientation, the use of vision and needs as a basis for planning, and the nature of the interventions to be developed, and team rules. Coordinate the Family Team members to recognize the strengths of each member. Coordinate the Family Team members to develop a plan of care that includes a vision, needs and interventions that relate to their identified strengths. Involve the family in identifying and planning for potential safety concerns. Identify and record preventative actions that promote stability and safety. Solicit feedback from the team members to ensure mutual understanding and consensus. Facilitate agreement in the decision-making to ensure accountability for follow-through by team members. Facilitate the development of a detailed crisis plan that outlines safety concerns, preventative actions, planned responses and a communication plan for alerting team members as needed. Follow-up with team members, especially those not in attendance, to ensure all team members are working on their assigned interventions and/or aware of the team s progress and status. Schedule minimum monthly team meetings and solicit participation of new and ongoing members for long-term commitment. IMPLEMENTATION Description: This phase follows directly after the initial Plan of Care and Safety Plan has been completed. During this phase the Participant and Family Team meets regularly with the express purpose of modifying and adjusting the Plan of 2
Care and Safety Plan based on information about the follow through and effectiveness of the interventions within the Plan of Care. The initial Plan of Care provides the framework for moving into the Implementation phase. Maintain team involvement with minimum monthly contact according to family need. Arrange, coordinate and modify interventions within the Plan of Care and Safety Plan by involving the entire team in the decision-making process. Provide, secure or arrange for supportive interventions & resources within the community or system. Coordinate the Family Team members in implementing the Plan of Care. Assist the Family Team in reviewing the usefulness of the interventions on the Plan of Care. Assist the Family Team in updating the Plan of Care, encouraging all team members participation. Increase access to supports and services to families. Develop and maintain records and documentation. Gather and review information to improve services to families by tracking and assessing family progress toward accomplishing the family s vision. Support, respond and/or arrange response to families during and after business hours. Maintain a focus on strengths, needs and creative interventions to inspire team members to continue focusing on problem-solving. Empower the team members to follow through on tasks they have agreed to do and find ownership in the plan of care. Help the team find strategies for utilizing natural and informal resources for formal services as soon as possible. Help team members address and resolve conflicts in process, perspective, roles and strategies. Engage and welcome new team members by communicating team roles and past accomplishments and by helping new members understand their roles and goals within the team. Help families and/or the family team to recognize and celebrate successes as they occur. 3
TRANSITION Description: This phase occurs when the initial Plan of Care has been implemented and modified over time and the right set of interventions have been successfully delivered to produce the desired outcomes. Effective transition planning will occur in a thoughtful fashion which engages the entire Family Team in decision making, supports rather than abandons the family, and helps the Participant and Participant s Family move to a maximum positive functioning and self-sufficiency life free of system interference rather than simply moving the Participant and Participant s Family from services. The formal transition phase can range between two weeks and up to three months. Help the team assess the progress made toward accomplishing the vision and determine the appropriateness of a shift into the transition phase. Help the family & other Family Team members gain confidence in their ability to maintain their successes after Wraparound. Develop and practice crisis response strategies that the family will be able to use after the formal team process has concluded. Determine whether any resources will be needed after transition, and build linkage to ensure that those resources will be available. Recognize and than the team members for their participation and accomplishments. Prepare all necessary reports for referring and participating agencies related to the closing of the team process. 4
UNIVERSAL JOB SKILLS All employees will demonstrate: Communicate role, responsibility and agency philosophy in order to assure mutual respect, confidence and trust with the child, and other stakeholders. Provide nonjudgmental, unconditional support to the child and family. Assess for immediate safety and stabilization needs. Customize helping approaches to fit the family s uniqueness, personality, culture and interest. Report relevant information to the right people at the right time. Maintain a focus on strengths, needs and creative solutions. Utilize the family s expertise in problem solving and solution seeking. Work interdependently with others toward common goals. Respond to family s and children s needs in a timely fashion. Document progress notes in Wraparound file, and complete required documentation within established timeframes. Instill hope for the future by communication and behaving with confidence and reassurance. Apply strength based, Wraparound concepts to plans and actions with families. Cooperate with Wraparound staff as well as other Family Team members. Demonstrate cultural sensitivity for youth and families. Participate in Wraparound Training, including 4-day training. Consult with supervisor when needed. Engagement Meet and engage the family communicating compassion, support, respect and enthusiasm for them and your role as a helper. Support family during stabilization by providing rest, relief and safety. Deescalate safely, effectively and confidently. Communicate and coordinate with other involved staff and team members. Planning Communicate any observed needs to the appropriate coworker. Communicate safety concerns to the appropriate coworker. Provide input and feedback in the development of the plan. Attend child and family team meetings as requested to participate in planning. 5
Implementation Discuss/communicate your role in the plan with the family. Recognize signs of impending crisis and effectively work to diffuse the situation. Assist families in accessing entitlements. Adapt and modify activity to fit the immediate situation. Reassure the family with coaching and calming techniques. Model and teach appropriate social behavior and skills. Communicate consistently and positively with the child/youth in ways they can understand. Sets, communicates and consistently implements appropriate boundaries. Connect and introduce youth and family to activities in their own community. Assessing, planning and implementing activities that promote continual growth, self expression and awareness. Identify and access positive relationships for the child and family. Provide direct supervision and redirection of children. Focus on strengths, needs, and creative solutions, and inspire others to follow this format in problem solving. Communicate and coordinate with the parent and others around schedule and activities. Attend ongoing team meetings as necessary to make recommendations and modifications to the plan. Build youth capacity and communicate with others about what the youth does well. Summarize progress toward goals and any extraordinary occurrences. Seek assistance and report incidents to the right people at the right time. Transition Rehearse crisis drills/coping with family. Focus on successes and plans for future with confidence. Help transition supports into place (including introductions of new supports). Explore and identify natural community resources (family, or work peers). Develop methods of youth and families to say goodbye to service providers with a culturally and socially appropriate ending process. CELEBRATE! 6