An Orientation Manual. For Nurses Working in DCF Regional Offices

Transcription

1 An Orientation Manual For Nurses Working in DCF Regional Offices DCF Regional Resource Group Nurses, February, 2013

2 The DCF Regional Resource Group Nurse: An Orientation Manual for Nurses in DCF Regional Offices A volunteer committee of six Regional Resource Group Nurses met from spring, 2012 to January, 2013 to create this Orientation Manual. The nurses recognize from first hand experience that the structure and functioning of any state agency can be confusing for a nurse who has not been part of a similar bureaucracy. In addition, their interest to participate on the committee stemmed from a strong commitment to provide guidance for any new nurse assigned to a DCF Regional Office, and to encourage all new nurses to seek out the assistance of one of their colleagues among the DCF Regional Resource Group Nurses (RRG Nurses). Their belief is that through consistent inter-group communications, the RRG nurses can provide insights and support as new nurses discover the complexities of a nonmedical bureaucracy in which the nursing care that emerges through that collaboration will benefit DCF children and youth. Committee Membership: DCF Regional Offices: Dielka Brutus, RN, Meriden Office Elizabeth Bowen-Connor, APRN, Bridgeport Office April Davis, RN, Middletown Office Louise LaChance, RN, Stamford/Norwalk Offices Christina Santoni, APRN, New Haven Office Iris Thompson, RN, New Britain Office DCF Central Office: Anne Kiwanuka, APRN, BC, Clinical Nursing Director, Central Office Proof-reader: Kimberly Kanaitis, RN, Hartford Regional Office 2

3 Table of Contents Page The Orientation Manual 4 Introduction 5 History of Regional Resource Group Nurses at DCF 5 Chapter One 7 Role and Responsibilities for Nurses in DCF Regional Offices 7 Chapter Two 11 Orientation to the Department of Children and Families 11 Nursing and the DCF Child Welfare System 14 Chapter Three 18 Communication 18 Appendices Appendix A RRG Nurse Orientation Checklist 22 Appendix B Chart for Topics & Types of Regional Resource Group (RRG) Nurse 23 Appendix C Acronyms in Child Welfare 27 Appendix D DCF Status Definitions 29 Appendix E Children Designated Medically Complex 30 Appendix F DCF Nursing Website 31 Appendix G DCF Health Advocate 32 Appendix H DCF Centralized Medication Consent Unit 33 Appendix I Finding phone numbers for staff in Area Offices and finding telephone numbers for DCF facilities 34 Appendix J The Differential Responses System: Commissioner's Memo, Sept Chief of Quality and Planning Memo, Jan,

4 The Orientation Manual In this Orientation Manual, information is offered describing the Regional Resource Group nurses (RRG nurses) who work with children involved with DCF. Their roles within different settings are described. The first Chapter covers the range of roles and responsibilities for DCF RRG nurses. Although all of these nurses work full-time, the scope of responsibilities differs in each Regional Office. One measure of professional nursing practice among the RRG nurses is their ability to adapt nursing responses to the unique requirements of the Regional Office in which they work Chapter Two provides a brief orientation to the complexities of a state agency bureaucracy, the Department of Children and Families, (DCF). With description of the complex structure of this sizable bureaucracy, it is hoped that new RRG nurses will have a more accurate picture of the work environment for RRG nurses. The locations of Regional Offices, the names and locations of DCF-operated facilities, and the locations within Central Office in which nurses work will be found in this chapter. Since there will always be changes in personnel over time, the names of individual nurses are not provided in this Manual. A new RRG nurse may follow directions given in an Appendix to locate a specific RRG nurse. New RRG nurses will also find in this chapter definition of many legal designations, such as a "96 hour hold," and children designated "medically complex," which governs decisions made by DCF social work staff. A description of the Differential Response System (DRS) used by social workers at the initiation of a new family case is found in this chapter. Acronyms used within the child welfare system, and further definitions of legal status, such as "statutory parent," and a "neglect OTC," are provided in Appendix D. Chapter Three provides information to assist a newly hired RRG nurse to learn about strategies that enhance communication between the RRG nurse, other DCF nurses, and nurses working in non DCF facilities. The "chain of command" structure used by social workers is explained. Ideas about when nurse-to-nurse collaboration can be helpful and when barriers to effective communication occur during a DCF case are briefly identified. Brief descriptions of a few key forms can be found in this chapter. The need for effective communication between non DCF facility nurses and DCF nurses is stressed. The Appendices include an RRG nurse checklist and a chart identifying a variety of reasons an RRG nurse may receive a request for consultation. There is an extensive list of acronyms used in social work practice, directions to access the DCF Nursing Website, and other useful information to guide acclimation of a new nurse to the DCF system such as: Services available from the DCF Health Advocate and contact protocols Information about children designated by DCF as "Medically Complex" Information regarding the DCF Centralized Medication Consent Unit It is our hope that this Orientation Manual will serve as a useful initial guide for new RRG nurses as they become familiar with the complexities of the Department. It is with sincere appreciation and gratitude that we extend a warm Welcome to the new Regional Resource Group Nurse. 4

5 INTRODUCTION The Department of Children and Families provides child welfare services for approximately 36,000 children and 16,000 families every year. Of these children, as many as 4,000 children are "in placement" living in environments other than the home of their birth parents. The Department's goal for all children in care is to improve child safety, ensure that more children have permanent families, and advance the overall well-being of children. DCF protects children who are being abused or neglected, strengthens families through support and advocacy, and builds on existing family and community strengths to help children who are facing emotional and behavioral challenges, including those committed to the Department by the juvenile justice system. Although DCF employs approximately 3,456 full-time staff, only a small number of those employees are nurses. There are currently twenty nurses working in the fifteen DCF Regional Offices across the state. Nurses working in Regional Offices are part of an interdisciplinary team, the Regional Resource Group (RRG), which provides resources for the social workers. Additional RN's and APRN's work in the DCF Central Office and approximately 90 nurses are employed in the four facilities operated by the Department. Those facilities are the Albert J. Solnit Children's Psychiatric Center- North Campus in East Windsor and the South Campus in Middletown; the Connecticut Juvenile Training School (CJTS) in Middletown; and the Wilderness School in East Hartland. History of Regional Resource Group Nurses at DCF In 1989, two children's advocacy groups filed a class action lawsuit against the state of Connecticut in federal district court. The lawsuit, Juan F. vs. O'Neill, et. al. Civ. No.H AHN, was brought on behalf of all children in foster care and those at risk for abuse and neglect. As the defendant, the Department of Children and Youth Services, the predecessor of the current Department of Children and Families, was held accountable to assertions by the plaintiffs that approximately 100 agency practices violated children's rights under federal child protection laws and the Constitution. The claims against the state were based on inadequate funding of child welfare services. From this lawsuit, a stipulated agreement, the Juan F. Consent Decree, was reached in Departmental plans for improvements included creation of fully trained Regional Resource Groups (RRG). In 1993, the department began hiring Registered Nurses to provide health care expertise in each Regional Resource Group. Nurse Practitioners joined Regional Resource Group teams starting in Today's RRG teams are composed of professionals in mental/behavioral health, substance abuse and nursing. They provide consultation, direct service, care coordination, policy interpretation, administration, and training to supplement, but not supplant, the decisions of DCF social work staff. 5

6 Regional Resource Group Nurse History (Continued) Over the past twenty years, the role of nurses in assisting social work staff to understand health care needs of DCF clients and discovering ways to meet those needs have become well established. DCF staff, community health care providers, parents, and other agencies routinely seek the RRG nurse's expertise in order to better assess a child's well being. RRG Nurses develop health treatment plans, ensure that children are being seen by the appropriate health care professionals, arrange for follow-up care, guide interventions when a child is not receiving recommended care, and identify and address barriers that lie between a child and good health care. When visiting children in an out-of-home placement or in their home, in a clinic or hospital, in school or day care, RRG nurses play an indispensible role as part of the Regional Resource Group team. Without RRG nurses, navigating the complex and comprehensive health care network would be far more difficult for child welfare agencies in Connecticut. The participation of Regional Resource Group nurses improves health outcomes for DCF clients and assists the Department of Children and Families to meet federal requirements. Today there are fifteen Regional Offices in which twenty nurses work. Offices serving large populations of clients, such as New Haven and Hartford offices, are assigned two nurses. In some locations, one nurse must serve the needs of clients in two neighboring Regional Offices. Working in an environment whose primary orientation is not medical, but rather, the social work discipline, these nurses rely on the knowledge and skills of every nurse and provider who comes into contact with a DCF child. 6

7 CHAPTER 1 Roles and Responsibilities for DCF RRG Nurses Any nurse who accepts a position in one of the Regional Offices must be securely grounded in professional level standards for nursing while accepting the challenge of adapting to a nonmedical setting. Values and beliefs associated with nursing and medical perspectives are often not the primary concern within these settings. The need to exercise skillful negotiation with various staff in order to guide, and even teach, employees in these settings about the critical impact of good healthcare on overall success in an individual child's placement remains ever-present for any nurse who works here. It is apparent that nursing in child welfare offices requires unique skills in adaptability, communication strategies with nonmedical personnel, and clear commitment to the highest standards of professional nursing. In their role, the DCF RRG nurses create a strong nursing community through collaboration with all the nurses employed by the Department of Children and Families and those working in non-dcf settings. Health Monitor Health Instructor RRG NURSES Nurse Consultant Care Coordinator Health Policy Consultant Community Liaison The six primary roles of an RRG Nurse are: Nurse Consultant Community Liaison Care Coordinator Health Instructor Health Policy Consultant Health Monitor These six roles are interconnected, sometimes overlapping. When an RRG nurse becomes involved with a DCF case, s/he determines which of the roles are needed. More than one 7

8 role is often appropriate and roles may shift as continuous assessments are made. A consistent requirement for nurses working in child welfare agencies is to be flexible and adaptable. To describe the roles and responsibilities of the RRG nurse, the following statement has been provided by the current RRG nurses. Nurse Consultant Nursing consultation is a significant aspect of the RRG nurse's job. The entry point for RRG nurse involvement often occurs as a request for consultation regarding the health or medical needs of a DCF client. Requests for consultation can come from DCF staff, community providers, or foster parents. Consultations may take place in a DCF office, in a home environment, or in a clinical setting. The primary purpose of the RRG Nurse is to serve as a consultant to the social work decision-making process. As a Nurse Consultant, the RRG nurse's tasks are largely determined by the needs of both the DCF client and the social worker assigned to that case. The following are some examples of an RRG nurse's tasks as consultant:: Respond promptly, frequently by or telephone, to requests from various DCF staff or others Prioritize responses to place more critical cases first. This task requires skills in triage and critical decision-making Clarify with the requester the type of service needed or level of concern Review prior to scheduled meeting with a social worker background information which may include LINK narratives, Medical Profile, Intake narrative, Case Record and Case Plan Document consultation and specific nursing recommendations It is not unusual that the "requester" may not know what type of care is needed, but recognizes that some form of medical/health care action is required. The Nursing Process is a valuable tool for identification of unmet health/medical needs of a DCF client. A more detailed list of types of nursing consultation can be found in Appendix B. Community Liaison RRG nurses often act as liaisons between the Department of Children and Families and community health providers or services. The RRG nurse may also act as liaison between other state agencies. A primary role in this capacity is to communicate about, and advocate for, the health and medical needs of children. Some examples are: Attend Planning and Placement Team (PPT) meetings for a child with medical needs to ensure the child's education team understands the nature and scope of the health/medical care needs Assist a hospital task force to develop policy regarding the discharge of high risk newborns Attend Department of Developmental Services (DDS) meetings to assure the successful transition of an adolescent with medical needs into appropriate DDS care Skill in interpreting information for non-medically trained individuals along with knowledge about nursing, medicine, and the protocols of DCF is vital for success in this role. 8

9 As a Community Liaison, the RRG nurse plays a critical role in facilitating communication of health care requirements for DCF clients. This work involves discussions with various community providers, for example, members of the DART Committee at Yale New Haven Hospital, Multiple Disciplinary Exam (MDE) Clinic professionals, pediatric specialists, and local hospital providers. Care Coordinator Care coordination is often defined as a process that links families and children with appropriate services to support optimal health outcomes. In Nursing, the term "optimal health" embraces all aspects of health possible within the confines of a person's health state. For this reason, the RRG nurse addresses health care from a holistic perspective. Coordination of appropriate follow-up, continuity, and evaluation of care from a variety of services is an essential function of the RRG nurse. Through use of the nursing process, the RRG nurse identifies unmet health care needs and guides the social worker in development of an appropriate plan of care. Below are some examples of an RRG nurses' actions: Contact health care providers, arrange and attend appointments when rapid delivery of services is necessary Attend medical (and other provider) appointments to assist in the development of family/provider partnerships Meet in group home settings with DCF clients and the provider nurse to plan actions steps with measurable goals Communication with providers based on a thorough review of medical and nursing documents is a key element of care coordination. An example of the need for excellent communication is evident in the discharge planning for children with complex medical needs who are being placed into, or out of, a residential facility, group home or foster home. A similar requirement for excellent communication occurs when coordinating "child specific" training for caregivers of children with complex medical needs. The term "medically complex" is a social work designation rather than a nursing/medical term. Health Instructor RRG nurses are responsible for helping DCF social workers understand health care policies and practices. Social workers need to know how and when to use certain health forms and their subsequent responsibilities in order for the Department to comply with mandated measurements of positive health outcomes in DCF clients. The RRG nurse may be required to provide training on health-related topics, or the proper use of various DCF forms as well as DCF health-related policies. The audience for these training events can be DCF staff, community providers, the client, or foster parents. It is important to note that health instruction does not include "child specific medical training" for foster parents and back-up caregivers. Some examples of health instruction provided by an RRG nurse include: Provide training for social workers regarding the correct use of the forms which obtain legal permission for various health procedures Provide training for foster parents on a range of health conditions such as Shaken Baby Syndrome/Abusive Head Trauma 9

10 Provide training for DCF staff and community providers regarding DCF regulations and health policies Health Policy Consultant The RRG nurse is frequently asked to help in development, review and implementation of health policy and practice. The focus of this consultation differs from the nursing consultation as identified above. It has direct implications for administrative decisions within the Department when those decisions relate to health and medical needs of a child. Some examples of health policy consultation include: Participation on a committee to update breast feeding policy Consultation with a DCF manager regarding the placement of a child with a complex medical condition Participation in a case conference with non-medical providers in which the RRG nurse offers advice regarding health policy, best practices in health care, and recommendations for use of resources Attendance at court as a nurse expert witness Although the Department has a designated unit at Central Office in which policies are drafted and vetted prior to publication, the RRG nurse may be requested to participate directly in the development of new health policies and procedures, or the clarification of health-related components of established policies. Health Monitor The RRG nurse is a key stakeholder in ensuring that health monitoring is an integral aspect of case management for all DCF clients. All children who enter DCF care must receive a Multi-Disciplinary Exam (MDE) and have all aspects of the Episodic and Periodic Screening and Diagnostic & Treatment (EPSDT) completed as recommended by the American Academy of Pediatrics. When children are known to have complex medical needs, RRG nurses work with the assigned social worker to monitor these children regularly and ensure that they are receiving the necessary medical care. Attendance at various social work meetings provides the RRG nurse with opportunities to strengthen health monitoring. Tasks associated with the role of Health Monitor include: Review MDE reports and work with social work staff to develop a blueprint for implementation of the recommendations in those reports Review the Quarterly Nursing Assessment (QNA) reports from facility nurses Attend Administrative Case Review (ACR) meetings and Team Decision-Making (TDM) meetings 10

11 CHAPTER 2 Orientation to the Department of Children and Families The Department of Children and Families is a state agency dedicated to child welfare, also referred to as child protective services. The current mission of the Department is that each client be healthy, safe, strong, and learning. Along with social work, other disciplines provide assistance in achieving these goals. The organizational structure of the Department centers on three operational teams: 1. Clinical and Community Support/Consultation Team 2. Child and Adolescent Development and Prevention Team 3. Residential and Institutional Facilities Team Child Welfare: The Regional Offices The Department of Children and Families includes 15 Area Offices, which are divided into six regions, along with the Careline at Central Office, the Special Investigations Unit, and the Office of Foster and Adoptive Service. The child welfare unit currently employees a workforce of approximately 1,900 employees including Social Workers, Social Work Supervisors, Program Managers, Office Directors, and Regional Administrators. 15 Regional Offices of DCF Region 1 (Bridgeport, Norwalk, Stamford) Region 2 (Milford, New Haven) Region 3 (Middletown, Norwich, Willimantic) Region 4 (Hartford, Manchester) Region 5 (Torrington, Danbury, Waterbury) Region 6 (New Britain, Meriden) See Appendix I. for directions to locate telephone numbers for each DCF Office DCF Facilities There are currently four facilities maintained by the Department of Children and Families. They are: The Albert J. Solnit Children's Center South Campus, Middletown, CT The Albert J. Solnit Children's Center, North Campus, East Windsor, CT Connecticut Juvenile Training School, Middletown, CT The Wilderness School, East Hartland, CT The Albert J. Solnit Children's Center, South Campus is the only state-administered psychiatric hospital for Connecticut's children who are under the age of eighteen. The hospital provides comprehensive care to children and adolescents with severe mental illness and related behavioral and emotional problems who cannot be safely assessed or treated in a less restrictive setting. Twenty-four hour nursing supervision is provided for patients. 11

12 The Albert J. Solnit Children's Center, North Campus provides brief treatment, residential care and educational instruction for children (many of whom have a history of abuse and neglect), who have behavioral health care needs. The ages range from 10 to 18 years and children come from all across the state. Nursing supervision is provided. Connecticut Juvenile Training School is the state's only secure treatment facility for boy's ages years who are committed delinquent. Its mission is to prepare residents for successful re-entry into the community. Nursing supervision is provided. The Wilderness School is a prevention, intervention, and transition program for adolescents in Connecticut. The program is supported by DCF, in additional to a tuition fee which is subsidized by a significant private funding base. The Wilderness School offers high impact wilderness programs intended to foster positive youth development. The programs are based on experiential learning and are considered therapeutic. Studies have documented the School's impact on self-esteem, increased locus of control, and interpersonal skill enhancement. There are no nurses employed at this facility. See Appendix I for telephone numbers, FAX numbers and addresses of each of the DCF Facilities. DCF Central Office The Central Office for DCF is located in Hartford. There are a number of nurses employed at Central Office. Within the Child and Adolescent Development and Prevention Section alone, there are six nurses who carry out a variety of responsibilities DCF-Licensed Congregate Care One Central Office nurse, who is an APRN, is engaged in promoting continuous improvement in the quality of healthcare provided each child residing in a DCF-licensed facility. This APRN conducts evaluations of clinical, medical, and nursing performance in these facilities. The functions of this nurse are consistent with Section 17a of DCF Agency Regulations regarding medical, dental and nursing care in Residential Facilities, Group Homes, Temporary Shelters and similar institutions. Medication Administration Program The Medication Administration Training program has been developed in accordance with State of Connecticut General Statutes 370 Section 20-14h-j, and DCF Regulation 17a-6(g) , to provide training for medically-unlicensed persons to safely administer medications to children in DCF contracted/licensed facilities. The responsibilities of the two Nurse Clinical Instructors in the Medication Administration Program include training employees who work in DCF-licensed child caring facilities, developing and updating curricula, scheduling trainings and maintaining a database of all employees trained. They also provide training for nurses working in facilities to become DCF Endorsed Instructors. The nurses in the program also act as liaisons to provider nurses in the community for programmatic, administrative, and training issues around medication administration. The nurses work closely with the Regulatory Consultants in the Licensing Division on medication administration issues and medication error review and follow-up. 12

13 See the Operations Manual for information about the DCF Medication Administration Handbook, July, One Central Office nurse is a Clinical Education Specialist. The primary responsibility is to design and present trainings for the preparation of Endorsed Instructors for the Medication Administration Training Program through the DCF Academy for Family and Workplace Development. The Clinical Specialist also assists other DCF personnel with curriculum development, preparation of manuscripts, manuals and other written materials. Medically Complex Foster Care Two Central Office nurses work directly with foster parents, preparing them to handle the care needs of children identified by DCF as medically complex. These nurses provide required training for prospective foster parents prior to their receiving a medically complex child into their care. The Centralized Medication Consent Unit (CMCU) Within the Clinical and Community Consultation and Support Team, there are two nurses assigned to the Central Medication Consent Unit (CMCU). This unit was created in September, 2007 for the following responsibility: To review and make decisions regarding requests for consent by providers to prescribe psychotropic medications for DCF-committed children/youth. Most psychotropic medications are used "off label" in the treatment of children and, thus, require additional expertise and review due to the potential side effects and drug interactions which may potentially place DCF children at risk. See Appendix H. to access forms and guidelines from the CMCU *For children committed to DCF, consent from the CMCU must be obtained to administer any psychotropic medication to the child. **The DCF Form 465 should be sent to the CMCU upon admission of a child/youth to the new facility without interruption in the youth's medication regime. The following chart indicates, according to the legal status of the child, who is responsible for providing consent for treatment:* Legal Status of Child Consent needed and by whom Statutory Reference Voluntary Parents FWSN** Parents Committed Delinquent Parents 96-hour Hold Parents 17a-101g(f) OTC Parents Committed Abuse/Neglect DCF 46b-129(j) Committed/Dual (parole) DCF TPR/Statutory Parent DCF 45a-718(b) Age of Majority clients/not committed Self (or legal guardian) * DCF Policy ** FWSN = Family with Service Needs 13

14 Nursing and the DCF Child Welfare System DCF Nurses' General Description The Department of Children and Families employs approximately 100 nurses. The majority work in DCF operated facilities such as the Albert J. Solnit Children's Psychiatric Center South or the Connecticut Juvenile Training School. Only twenty nurses are placed in DCF Regional Offices serving as many as 80 social workers per office. In the DCF Regional Offices: Nurses function as consultants for DCF staff, care providers, and the children and families who are served by DCF. In the Central Office: Nurses teach medication administration, train foster parents, train social workers, consult on psychotropic medications, consult with pediatricians, psychiatrists and other care providers, and collaborate with nurses working in DCF-licensed child care facilities. There is a strong history of consultation and collaboration with the Regional Resource Group nurse. In DCF Facilities: Nurses' staff 3 shifts, manage hospital care, admissions, treatment planning, discharge planning and educate clients regarding specific health care needs. Terminology For nurses to be able to work within DCF, they must learn basic concepts of child welfare. Below are some critical concepts which RRG nurses are likely to encounter when a child comes into DCF care. These concepts represent legally binding rights and responsibilities of the Department. Additional legal terms can be found in Appendix D 96 Hour Hold- This is a legal action in which DCF has the right to remove a child from the custody of parent(s)/ guardian(s) for up to 96 hours to ensure the child's safety. This requires a signed authorization by a DCF Program Supervisor or another DCF manager of equal or higher grade. During this time, DCF becomes the "custodian" of the child. The parent is still the guardian, and retains all rights as guardian. The "custodian" must take care of the child's basic daily needs such as food, shelter, education and basic/emergency medical care. OTC (Order of Temporary Custody) this is a court order made by a judge using reasonable cause as the standard for decision making. It is enforced by the police. Once an OTC has been issued, a hearing is scheduled within the next ten business days so that parents have the opportunity to present their case. The parent is still the legal guardian and retains all rights as guardian. Commitment-In this legal action, the child is removed from the home, and DCF is awarded guardianship of the child. Parents retain parental rights; however they are no longer the child's guardian. They are permitted visitation, are invited to Administrative Case Review meetings, etc. TPR (Termination of Parental Rights) this is a legal action made by a judge in which parental rights are terminated. Termination means a complete severance by court order of the legal relationship with all its rights and responsibilities, between the child 14

15 and his parent or parents so that the child is free for adoption. This severance does not affect the right of inheritance of such child or the religious affiliation of such child. Voluntary Services This refers to a range of services for which the family must make a specific request. These services, including casework, community referrals, and treatment services, are provided for children who are not committed or in the legal custody of DCF. DCF facilitates services through contracts with service providers. Dual Committed/Adjudicated This term refers to a child/youth that has been committed to the Commissioner of DCF for guardianship (Neglect/Uncared For) and also is committed to DCF due to a finding of guilt for delinquency. The delinquency commitment is for judicial custody only and by law has no impact on the rights/responsibilities inherent to guardianship. However, dual commitment transfers guardianship to DCF. Differential Response System In addition to knowledge of social work terminology, the RRG nurses must also be informed about the current social work practice protocols. Recently, DCF implemented a new approach to social work decision-making regarding a family's need for service called the Differential Response System (DRS) In March, 2012, the Department initiated a major reform in how the agency responds to reports of abuse or neglect in families that are not at high risk and whose children are safe. Nationally known as the Differential Response System (DRS), this reform in child protective service improves participation by families in their own case plans and treatment. Approximately 40% of reports to the DCF Careline are now handled through this approach. All cases receive a safety and risk assessment. Low and moderate risk cases meeting all other criteria initially are assigned to an alternate track, Family Assessment Response, (FAR). The relatively small percentage of cases that suggest acts of committed, emergent, or serious harm to a child are handled through the traditional, forensic-style investigation approach. Some examples of cases in this category include reports of physical or sexual abuse, potential criminal charges, homes with two or more previous substantiated investigations, a previous Superior Court adjudication of abuse or neglect, or a previous assessment of high risk. Gaining family participation holds the promise for increased client satisfaction, a more prompt access to services, reduced likelihood of families returning to the attention of child welfare, no increase in children being unsafe, and a decrease in the recurrence of child maltreatment. (See Appendix J for more details) In the diagram below, the label "Intake" signifies those cases which are assessed to have higher risks of child maltreatment. The "Family Assessment" track represents those cases with low or moderate risk. 15

16 Differential Response System CARELINE DCF Referral Family Assessment Lower Risk Cases (72-hour responses) 15 Rule Outs Determine Appropriateness Face-to-Face Contact within 5 days Protective Factors Assessed Service Plans & Family Team Meetings 45-Day Completion MAIN FOCUS Services Recommended Services Not Needed Transfer for Continued Services determined by Partnership through use of Risk Assessment Can Switch Between Tracks Based on Safety Assessment Intake Response Times (Same Day/24/72) Investigation Mandated Collateral Contacts Case Decision & Central Registry 45-Day Completion MAIN FOCUS Substantiation or Unsubstantiation Transfer for Ongoing Services mandated by DCF through use of a Risk Assessment Along with the change in family assessment, DCF has also instituted a new model for social work practice, the Strengthening Families Practice Model. Its primary focus is family participation in social work visits; safety, risk, and family assessment, case planning and individualized services. (See Appendix J for more details) There are seven strategies in the Strengthening Families Practice Model. 1. Family Engagement 2. Purposeful Visitation 3. Family Centered Assessment 4. Supervision and Management 5. Initial and Ongoing Assessments of Safety and Risk 6. Effective Case Planning 7. Individualizing Services All families are assessed, not only for risk factors for child abuse, but also for "protective factors." The five Protective Factors are: Nurturing and Attachment: Building a close bond helps parents better understand, respond to and communicate with their children. Knowledge of Parenting - Child and Youth Development: Parents learn what to look out for at each age and how to help their children reach their full potential. Parental Resilience: Recognizing the signs of stress and enhancing problem-solving skills can help parents build their capacity to cope. Social Connections: Parents with an extensive network of family, friends and neighbors have better support in times of need. Concrete Supports: Parents with access to financial, housing, and other concrete resources and services, that help them meet their basic needs, can better attend to their roles as parents. 16

17 Six Cross-Cutting Themes Lastly, the Department uses six cross-cutting themes to guide changes in child welfare. They are: 1. Strengthening family-centered practice and programs agency-wide 2. Expansion of trauma-informed practice 3. Application of the neuroscience of early childhood and adolescence 4. Expanding service and support for families at the community level 5. Improved leadership, management, supervision and accountability 6. Advancing DCF as a learning organization The RRG nurse may be called upon at any point in the assessment and decision-making process regarding the needs of a family. See Appendix J for Commissioner's Memo, Sept., 2010; a Memo from Chief of Quality and Planning, Jan, 2012, and web link to32-page report on Connecticut's adaptation of the Differential Response System. 17

18 CHAPTER 3 Communication Communication within a large bureaucracy requires knowledge about the established communication pathways. At the Department of Children and Families, this communication pathway is referred to as "The Chain of Command." In addition, the command structure in each Regional Office can vary slightly. Much time can be lost trying to navigate through the many layers of the system if the RRG nurse is unfamiliar with the chain of command. When the well-being of a child is at stake, the ability to quickly reach the one person who can help is essential. The DCF Chain of Command starts with the child's social worker: *DCF Chain of Command in Regional Offices Commissioner Regional Administrator (RA) Area Director (AD) Program Manager (PM) Social Work Supervisor (SWS) Social Worker (SW) * This information can be found on the DCF Website: Go to the DCF Website and follow these steps. Click "About DCF" blue tab at the top of the page: scroll down through the Index to "C;" Click "Contacting DCF Offices or Worker". See Appendix I. for directions to find telephone numbers for Regional Offices Communication with social work staff and other nurses Communication between social workers and the RRG nurse can be formal or informal. The RRG Consultation Form provides a mechanism to formalize and track nursing consultations. This form is informal in the sense that it is not a DCF numbered / official form. However many area offices use this format to request, organize and track the RRG unit workload. A new RRG nurse will find a detailed list of forms commonly used at DCF along with samples of correctly completed forms in the Operations Manual for Regional Resource Group Nurses (currently under construction). There are forms specifically designed for nurse-to-nurse, and nurse-to-social worker communication. Below are listed names of important forms which a new RRG nurse should become familiar with. 18

19 FORMS Form 2102: Placement Plan for a Child with Complex Medical Needs. This form provides all the information needed when planning a placement for a child with complex medical needs. It includes such things as equipment needed, current medications, educational needs, and follow-up appointments. This form is used as part of discharge planning for children with medical needs. Form 460: Informed Consent for Necessary or Emergency Health Care or Referral. This form is used to obtain informed consent for various medical and surgical procedures or treatments. For information regarding who must provide consent when a child's legal status is one of eight possibilities, see page 14 in this manual. Form 460A: Permission to Deliver or Obtain Routine Health Care. This form must be completed by the social work when obtaining permission for DCF to provide health care to a child. The form identifies all the required routine medical/health care for a particular child, including check-ups and tests, immunizations, assessment of health risks, and health lifestyle counseling. When the social worker completes all the requirements of this form, less time and effort is required each time a child moves. A copy of this form is given to the placement setting for all committed children. Form 2101: Certification of a Child's Complex Medical Needs. This form is used to determine whether a child meets criteria for the designation of medically complex. The RRG is required to review and sign this form. Other key forms: Form 785: Medical Review Board Referral Forms 2131(T) and 2131(F): Authorization for the Release of Information to the Department of Children and Families Nurse-to-Nurse Consultation and Collaboration Nurse-to-Nurse consultation between those nurses working in child care facilities and DCF nurses is highly valued and encouraged. Some examples of reasons to obtain Nurse-to- Nurse consultations include, but are not limited to, the need to: Discuss a child's medication needs Update a child's daily care needs, and treatments Complete a health history Facilitate obtaining releases from legal guardians Obtain information about the health insurance coverage for a child Complete discharge planning Consultation with another nurse can also involve collaboration on decisions that are in the best interest of the child. Through sharing insights of the Provider Nurse, the RRG nurse, and a nurse working at the DCF Central Office, these professionals can devise a combination of strategies tailored to meet the specific needs of one individual child. Collaboration requires not only respect for the insights of the other person, but also awareness of the possibility that a stronger solution may be derived through collaborating with each other. Some examples of circumstances in which nursing collaboration can improve the quality of a child's care are: 19

20 Offering tips on administration of a medication to a specific child Discussion of care requirements for serious conditions: Diabetes, asthma, allergic reactions, medication changes Discussion of care requirements regarding incidental health conditions: Head lice, bed bugs, eczema Discussion of care requirements which create special needs for Nurse-to-Nurse Consultation: Emergency care requirements, e.g. seizure disorder, diabetes crisis, asthma crisis Hospitalization requirements: e.g. surgical/medical procedures, psychiatric care Pre and post procedure requirements e.g. surgery The Quarterly Nursing Assessment (QNA) and the DCF Congregate Care Nursing Discharge Summary The Quarterly Nursing Assessment An RRG nurse may need to contact a nurse working in a DCF-licensed child care facility. These facilities are collectively referred to a Congregate Care Facilities. Nurses working in those facilities (called "provider nurses") collect health information about a DCF child using the Congregate Care Quarterly Nursing Assessment Report (QNA). Below are identified the sequence of actions that are triggered when a Provider Nurse sends a completed Quarterly Nursing Assessment to the appropriate DCF nurse. The DCF Congregate Care Nursing Discharge Summary This form is completed when a youth is discharged from a congregate setting. It is an excellent tool for the foster parent, new setting and new providers. Process for Sharing Health Information Presented by Anne Kiwanuka, APRN, and Terri Martens, Wheeler Clinic, Plainville at the Best Practice Seminar, June 11, 2010 Provider Nurses will complete the Congregate Care Nursing Quarterly Report and Immunization Record form**. This form will be ed to DCF to the appropriate social worker, the social work supervisor, the DCF RRG nurses and the Central Office APRN. The DCF social worker, social work supervisor and RRG nurse(s) will review the Congregate Care Quarterly Nursing Report and Immunization Record. The DCF social worker will be responsible to copy, paste and input information into the LINK system after clicking on the icon "Provider Nurse Quarterly Report and Immunization." The Provider Nurses will use the drop-down box on the Congregate Care Nursing Quarterly Report designated "Health Alert" for those children identified on the Congregate Care Nursing Quarterly Report as having medical issues. This report will be ed to the DCF social worker, social work supervisor, RRG nurse, DCF Behavioral Health Program Director, DCF Regional psychiatrist, and the Central Office APRN. The DCF RRG nurse will ensure appropriate follow-up and document his/her actions in LINK. 20

21 An individual assessment by the Provider Nurse regarding who to contact at DCF must be made for each child and for each situation. Subsequent to a thorough nursing assessment and determination of the nursing plan of care for that child, a Provider Nurse is encouraged to inform the individuals listed above. With the exception of a "Health Alert," these communications should be limited to the RRG nurse, the APRN in Central Office, the child's social worker, and the social work supervisor for that social worker. 21

22 APPENDICES Appendix A RRG Nurse Orientation Checklist The following is a list of important "to do" items that are specific to your Area Office: Request an orientation to your work area - building egress, parking, filling out time sheets, meet your RRG Unit team members, etc. Request an orientation to Central Office Meet with Link specialist to learn the basics of Link Meet with the Principal Attorney Meet with the Program Managers (PM) Familiarize yourself with the Medically Complex Unit and/or staff Familiarize yourself with the MDE Coordinator Familiarize yourself with the Human Resource representative Identify your 1199 representative Learn how to access DCF policies Learn how to access DCF templates 22

23 Appendix B Chart for Topics and Types of RRG Nurse Consultations. Topics and Types of Regional Resource Group (RRG) Nurse Consultations 1 Administrative Case Review The purpose of the Administrative Case Review (ACR) is to provide an orderly and structured meeting in which all participants are engaged in discussion focused on meeting the needs of children, including permanency planning. 2 Central Medication Consent Unit Why the Regional Resource Nurse at DCF may be consulted The nurse has provided assessment services i.e. home visit to the child or family within the six (6) months prior to the ACR. The child has medical and/or health needs that require nurse consult and/or service coordination. If there are questions or concerns regarding any aspect of the 465 process [Nurse receives CMCU s] 3 Child Death Assist in the forensic investigation. Identify and support family bereavement issues. 4 Child Specific Training Help coordinate with medical provider the training/education specific to child at time of placement 5 Critical Incident Medical and nursing expertise i.e. To help coordinate and communicate the health, medical and nursing aspects of the case and to make recommendations To help identify and explain health concerns and work collaboratively with providers for best outcomes 6 Dental If child needs dental work involving extensive work and/or sedation. If child has compounding medical or behavioral needs. Assist in What is the relevance to the community nurse provider The Quarterly Nurse Assessment information is transferable to case planning. Nurse may be asked to assist in coordinating medical, nursing and/or health related services identified in or resulting from the ACR. Nurse is aware of prescribed medication and is part of the monitoring of safety and health of youth in the setting. Psychotropic consent process information go to Identify and support peer group bereavement issues In some settings the nurse may be training/teaching staff based on medical orders. Report may be generated from a setting the nurse is involved with and there may be follow-up actions. Nurse may be a key person in coordinating dental appointments and post procedure care and services. 23

24 Topics and Types of Regional Resource Group (RRG) Nurse Consultations Why the Regional Resource Nurse at DCF may be consulted process of informed consent 7 Developmental Disability When the child has a co-morbidity and there are concerns about the child's health and well being. 8 High Risk Newborn Medical and nursing expertise i.e. To help coordinate and communicate the health, medical and nursing aspects of the case and to make recommendations To help identify and explain health concerns and work collaboratively with providers for best outcomes 9 Home Visit Child & family assessment when there are issues concerning medical / health conditions. 10 Hospital Discharge Planning Assist in the identification and coordination of medical and health related services post discharge. 11 In Home Cases Child & family assessment when there are issues concerning medical / health conditions. 12 Investigations Medical and nursing expertise i.e. To help coordinate and communicate the health, medical and nursing aspects of the case and to make recommendations Identification of risk factors 13 MDE A multidisciplinary exam done within 30 days of entry into DCF care. Identification of community based services and supports Review the report with SW - with the focus on unmet needs. 14 Medical Appointments Accompany youth and/or obtain health information and plan of care from provider. Health advocacy & promote health literacy. What is the relevance to the community nurse provider Help to maintain a developmentally and age appropriate approach to care and well being. Improved outcomes for babies RRG nurse may visit site and meet with youth and nurse and review nursing care plan and scope of care. Nurse responsible for completing the admission protocol. Collaboration with RRG nurse as to service and resources May be role for school or community nurse as to coordination of services There may be a role for nurse if youth placed early in the investigation process and there are unmet needs. There may be some continuity of care issues Assist in the identification of age, gender and developmentally appropriate resources. Accompany youth and/or obtain health information and plan of care from provider. Allows for improved communication of youths 24