COORDINATED CASE PLANNING WORK GROUP

Transcription

1 COORDINATED CASE PLANNING WORK GROUP RECOMMENDATIONS DECEMBER 2001 INTRODUCTION CalWORKs income support and employment services and Child Welfare Services (CWS) are programs typically offered by the same agency in most California counties. However, families requiring services from both programs routinely find that they are assigned one or more caseworkers for each program, asked many of the same questions by those different workers, and must agree to participate in a different service plan for each program. Each program has its own focus and goals with particular requirements and established time limits. The programs are so distinct that clients may not even realize that they are receiving services from the same agency. Families involved in both CalWORKs and CWS can benefit from a coordinated case plan that is thorough and comprehensive and avoids overlapping or conflicting assessments, plans, time limits, and requirements. Such a coordinated plan enhances achievement of family self-sufficiency and stability and thus supports the best interests of the children involved. Through improved screening and prevention services, coordination of CalWORKs and CWS can also make it possible, in some cases, for service providers to assist clients and their families to avoid public assistance or an active case in CWS. Table 1 on the next page summarizes how coordinated case planning in CalWORKs and CWS can help families and counties. Overall, the purpose of case coordination is not simply to coordinate, but also to improve outcomes for children and families, to promote safe and stable families, and to increase government accountability. Through this approach, coordinated case planning serves an overall county mission wherein CalWORKs is a primary prevention program for child welfare and CWS is an antipoverty program. Coordinated Case Planning Work Group Members Co-Chairs Members Wes Beers Susan Arteaga Rosemary Capobianco Bonnie Pierce Chief Deputy Director Assistant Deputy Director Program Specialist Manager Children s Services Department of Social Services Health and Human Services Agency Social Services Department CDSS Madera County San Diego County San Luis Obispo County Virginia Wilson Susan Brooks Lisle Smith Cohen Kathy Volf Program Manager Director Social Services Program Manager Client Services Director Community Services Agency Northern California Social Services Agency Health and Human Services Stanislaus County Children and Family Services Santa Clara County Yuba County Training Academy Jim Brown Jann Donnenwirth Facilitator: Linda Orrante Regional Advisor Program Manager Project Coordinator CDSS The Center for Human Services CalWORKs/Child Welfare Recommendations on Coordinated U.C Case Davis Planning Extension Page 1 Partnership Project CCRWF

2 Table 1 Benefits of Coordinated Case Planning How Coordinated Case Planning Can Help Families Coordinating services and providing quicker access to services can yield better outcomes for families because they won t have competing plans, goals, and timelines. Improved screening and assessment means that prevention services can be added, expanded, or offered earlier. One point of entry for families makes life easier for families who already have significant stress and few resources. Coordinated case planning provides more assessments, referrals, and intensive coordinated services for families with domestic violence, mental health, alcohol and drug abuse, and other barriers to self-sufficiency. A coordinated system can establish more accountability. There is less opportunity for miscommunication between families and staff. Families reduce the amount of time spent with program administration and increase the time spent in applying the skills learned. How Coordinated Case Planning Benefits the County Staff serving the same families have a common purpose and a stronger sense of community by reducing divisions between programs. Coordination of services means better use of existing resources funding, staff, and time. Administration may be able to set up policies and procedures once for both programs. Cost avoidance may result by reducing overlapping services and improving client outcomes and recidivism. Staff feel more knowledgeable, effective, and empowered; better morale among staff also helps with retention and recruitment. Coordination of programs may mean that the county can more effectively implement statutes and regulations. Recommendations on Coordinated Case Planning Page 2

3 WORK GROUP RESEARCH AND OBSERVATIONS Coordinated case planning is the lynchpin of a county s effort to offer coordinated services. The purpose of this document is to offer information and advice to county leaders interested in launching or enhancing coordinated case planning. As the Work Group researched coordinated case planning efforts both within and outside of California, several observations were key. Coordinated case planning is a concept that is widely known and supported, but the words mean very different things in different counties. Coordinated case planning is implemented in many different ways. Coordinated case planning is a concept that is widely known and supported, but the words mean very different things in different counties. There is no commonly accepted definition or model of coordinated case planning. The current use of the phrase indicates that in a county, there is, at minimum, an acknowledgement that families may have two different case plans and that the workers should communicate with each other to share information about the families needs. Based on interviews, research, and case studies, the Work Group also determined that when people discuss coordinated case planning, they often refer to different organizational arrangements: two or more case plans that are coordinated; or a single, shared case plan between the two programs. Furthermore, the Work Group observed that coordinated case planning can be implemented by having: a single point of intake or different points of intake; a single case manager or shared case management; and/or staffing only from CalWORKs and CWS, or a multidisciplinary team approach that also includes staff from other departments or agencies. The recognition that there is neither a common definition nor a standard model of coordinated case planning complicated the Work Group s original mission of developing recommendations about coordinated case planning. Consequently, the Work Group began with an analysis of the common features or elements of coordinated case planning and identified different types of coordinated case planning for the purposes of this briefing paper and the CalWORKs/Child Welfare Partnership Project. Using this approach, the Work Group developed recommendations to assist counties in the design and implementation of coordinated case planning. 1 The Work Group offers observations, guidelines, and recommendations in the following areas: the continuum of coordinated case planning; the five components of case planning; and administrative decisions related to coordinated case planning. 1 The Work Group also made state-level recommendations which are contained in the publication, Recommendations for State- Level Activities to Coordinate CalWORKs and Child Welfare Services. Recommendations on Coordinated Case Planning Page 3

4 THE CONTINUUM OF COORDINATED CASE PLANNING The Work Group observed that the degree of coordination for activities identified as coordinated case planning can be placed on a continuum. This continuum ranges from informal communication to a unified case plan. Informal Communication CalWORKs and CWS workers have knowledge that both programs are working with the same family. Workers in each system are encouraged to cross-check to determine if the family has an open case in the other program. Identification of mutual families (families in both systems) happens more or less depending on the worker and his or her supervisor. There are two independently prepared case plans. Supervisors encourage staff to discuss their cases with the other program worker as needed. Managed Informal Coordination The agency has written protocols to ensure the coordination of services. CalWORKs and CWS workers are informed when the same family has an open case in each program. The respective caseworkers are required to communicate with each other about the family s needs; e.g., after dually involved families are identified, caseworkers are required to meet together to share appropriate information they each have about the family. Workers develop two independently prepared plans, but they are required to share these with each other. One of the workers may be assigned as the primary or lead case manager for the family. There is a required process to evaluate progress by all parties; e.g., the lead case manager must talk with the other worker to update the plan and discuss the progress, or lack of it, on the plan. Linked Case Plans CalWORKs and CWS workers have a high level of coordination at the earliest opportunity and throughout the life of the case. The workers work together with the family to follow through on the family s prioritized service needs and activities. Formal protocols require workers to share information between programs when client and family needs are assessed. Two case plans are developed. The workers coordinate case plan goals, services, and timelines when possible to meet the prioritized needs of the family. The case plans include, as appropriate, any treatment plans with substance abuse, mental health, or other service providers. A primary case manager may be assigned. Workers from both CalWORKs and CWS may meet together with the family, e.g., joint home visits at critical junctures in the assessment, planning, and case implementation phases. The workers have regular contact with each other to track the progress of the two case plans. Adjustments are made to the case plans as needed. Recommendations on Coordinated Case Planning Page 4

5 Unified Case Plan One comprehensive case plan addresses the family s needs and stays with the family regardless of which program the family is involved in. A protocol requires one unified case plan when a client has an open case in CalWORKs and in CWS. Critical to this model is an accurate, joint/interdisciplinary assessment which identifies and describes the needs of the family regardless of how they entered the system. There is agreement between the family, the workers, and the service providers on the plan and desired goals/outcomes. The unified plan identifies: the services needed by the family, e.g., the action plan necessary to get to a sufficient/ideal resolution; the services that the county can make available to the family, whether funded through the TANF employment plan or the CWS plan; substance abuse and mental health goals as components of the same plan; the agencies that can provide services; and a case implementation strategy which includes time frames and deliverables for both the family and the workers. There may be a CWS court case component that, due to privacy, is not shared. There is one primary or lead case manager. The workers operate as a team on all aspects of the case from assessment to case resolution. Counties need to determine what degree of coordination best meets their goals for serving families. The Work Group strongly recommends that counties aim for the highest level of coordinated case planning possible in their organizations. Table 2 provides a comparison of the features of the different types of coordinated case planning. Table 2 Comparison of the Features of the Different Types of Coordinated Case Planning Features of Coordinated Case Planning TYPE OF COORDINATED CASE PLANNING INFORMAL COMMUNICATION Client Matching Encouraged Worker Communication Encouraged on as needed basis Coordination of Case Plans Two independently prepared plans; workers encouraged to share Primary or Lead Case Manager Two different case managers Evaluation of Progress Workers encouraged to discuss progress MANAGED INFORMAL COMMUNICATION Workers informed of common clients Required workers meet to share information Two independently prepared plans; workers required to share A primary case manager may be assigned Workers required to jointly evaluate progress LINKED CASE PLAN Formal protocol Required workers share assessment information Two case plans are developed in coordination with each other A primary case manager may be assigned Workers required to jointly evaluate progress UNIFIED CASE PLAN Formal protocol Required - joint assessment process One unified case plan There is one primary case manager Workers operate as a team to evaluate progress Recommendations on Coordinated Case Planning Page 5

6 THE FIVE COMPONENTS OF COORDINATED CASE PLANNING In addition to identifying various types and degrees of coordinated case planning, the Work Group concluded that most, if not all, coordinated case planning systems are designed using five components. 1. Client Identification and Referral 2. Team Development and Communication 3. Client and Family Assessment 4. Development of a Coordinated Service Plan 5. Case Management and Case Resolution County leaders need to determine how to configure each component in order to best implement coordinated case planning. In making decisions about each component, it can be helpful for line staff in CWS and CalWORKs to assess what will best assist their coordination efforts to serve families. At each point, it is also important to acknowledge and address the fact that some clients will fear losing their children (see Table 3). 1. Client Identification and Referral Administrators face a number of decisions in identifying the target families, decisions that affect the reach of prevention services and the efficiency of the coordination effort. Decisions must be made in three areas: choosing target populations, identifying clients, and referring clients. Choosing Target Populations Will clients be families who have an active case in both CalWORKs and CWS programs? The Coordinated Case Planning Work Group recommends beginning with these mutual clients. See Table 4 for a depiction of the kinds of families that can be served through coordination, identified along two axes: participants receiving or not receiving CalWORKs services; and participants receiving or not receiving CWS services. By identifying target populations that are or could be dually involved in both systems, counties can develop program linkages to more efficiently or comprehensively serve these participants and their families, including the provision of preventive services to prevent entrance into one system. Each county can make choices about which populations to target, based on that county s philosophy and resources. Counties can select one or several populations and continue to expand the types of families served as resources are developed. Table 3 Recipients Fear of Losing Their Children and Mistrust of the System Families may be reluctant to participate in coordinated services if they believe they can lose their children over issues such as mental health or alcohol and other drug problems, or domestic violence issues. These concerns need to be acknowledged and addressed with recipients prior to or as early as possible in their contact with the system. Both CalWORKs and CWS staff should acknowledge recipients concerns and be forthright about the policies of CWS. Each county should develop clearly written policies regarding what constitutes grounds for removal of children. These policies should be widely publicized in the community and made available through all recipient education efforts, such as those described in the Work Group report on confidentialitiy. It is important to note that policies and related education efforts will vary throughout the state. For example, some counties in California remove every child in a family when the parents have a drug problem, while other counties only remove the child if there is evidence that the drug problem is causing a risk or detriment to the child. Recommendations on Coordinated Case Planning Page 6

7 Table 4 Possible Target Populations for Coordinated Case Planning 2 In CWS but not in CalWORKs Families in CWS Family Preservation or Family Maintenance who are not in CalWORKs, but may be eligible for CalWORKs, CalWORKs Diversion, Food Stamps, or Medi-Cal Services Teenagers coming out of Foster Care who have children and are eligible for CalWORKs Non-custodial parents of children in CWS who are linked to CalWORKs families through the custodial parent Families with a current CWS Emergency Response investigation that will not be opened as a case Not in CalWORKs Not in CalWORKs and not in CWS Families not receiving CalWORKs, but meeting the needy family criteria Families not receiving CalWORKs, but receiving prevention services under the auspices of goals 3 and 4 of TANF Families referred for eligibility determination for Medi-Cal, Food Stamps, or Diversion Services Families referred by mandated domestic violence, substance abuse, or mental health reporters Not in CWS In CWS In CWS and in CalWORKs Families in CalWORKs and receiving CWS voluntary or court-ordered Family Maintenance or Preservation Services Families in CWS Family Reunification services eligible for CalWORKs 180-day employment services Families in CalWORKs with children in Permanent Placement Services Non-needy relatives In CalWORKs In CalWORKs but not in CWS Non-needy relatives Families who are in CalWORKs sanction Families who are reaching 60-month time limits Families with no CWS history, but with risk factors such as domestic violence, substance abuse, poor school attendance, and lack of compliance with CalWORKs requirements Families transitioning out of CWS with an ongoing CalWORKs case Families with prior Child Welfare history, e.g., referrals Teens in CalWORKs, including teen parents Kin-Gap families 2 The Work Group strongly recommends beginning the coordinated case planning effort with mutual clients, those currently in both the CWS and CalWORKs systems. Recommendations on Coordinated Case Planning Page 7

8 Identifying and referring clients Once the target populations have been chosen, the families that meet the designated criteria need to be identified. There are different ways to design your intake and screening to identify clients for coordinated services. Table 5 provides examples of different ways that counties identify clients and families. Below are some of the questions that county administrators need to address. Will clients be identified through a clerical process or an automated process? Or will identification occur during intake? If screening occurs during intake, will intake screen for one program or both? In making these decisions, consider staff size, training needs, capacity to co-locate, demands on participants, etc. See Table 6. How can intake in both programs be streamlined so that basic demographic information is collected only once prior to assessment? How often will the data on mutual clients be available? Weekly? Monthly? Quarterly? Who will receive the data? Will it go to both programs? What will be the responsibilities of those who receive the information on mutual clients? Will the family be informed that they have been selected to receive coordinated services? A Will the family be part of the decision- making about whether or not they participate in coordinated services? Can workers in CWS screen for possible need of income support or employment services? Can CalWORKs workers screen for families at risk of entering CWS? Eligibility and employment workers are mandated reporters which means they must be alert to any signs of child abuse or neglect, but actually screening for possible CWS needs is a prevention strategy. Table 5 Identifying Clients and Sharing Client Information Riverside County identifies clients through a weekly automated match system from the eligibility, employment, and CWS files. Yolo County has a full-time Public Assistance Specialist who identifies dual clients and provides follow-up to ensure that there is no break in program eligibility, thereby reducing barriers to various program service components. San Diego County has assigned an eligibility technician to identify and track all clients in both systems who are part of that agency s Substance Abuse Recovery project. On other cases, the social worker, eligibility technician, and employment case manager identify common clients and talk with each other. In El Paso County, Colorado, when a worker opens a TANF case, the worker checks for a CWS case. When a CWS worker opens a case, the worker checks for TANF involvement. There are two separate automated systems. All intake and screening workers have codes to access the two systems. Table 6 Options for Intake and Screening One intake process that screens for both programs. Each program has its own intake process. Some intake data is shared to avoid redundant requests for information from the family. Case plans are developed later in the process. Recommendations on Coordinated Case Planning Page 8

9 How can screening be used to offer diversion services to prevent entrance into a program? Intake may determine that a client is not eligible for a program, but that a client and his or her family are in crisis. What services can be provided to divert the client from needing more intensive services in the immediate future? Some counties (see Table 7) have devised intake procedures that identify near-crisis situations that can be assisted or resolved before they require intensive and more expensive services. How can screening address the needs of a program participant s family? Increasingly, county service providers are recognizing that helping clients often requires assisting all members of the family. Consider setting up initial intake to screen the family s needs (not just focusing on a parent or child) and determine eligibility for a myriad of county programs, including prevention services. It is important to establish that participation in prevention services should not be perceived by parents to be a requirement to qualify for CalWORKs. Services must truly be optional and have no penalties for non-participation. How can the concept of triage be effectively designed into the intake and screening system? Every participant who enters the CalWORKs system does not need intensive services, either individually or for his or her family. Every client who Table 7 CalWORKs Diversion Services in San Luis Obispo CWS Emergency Response workers are trained to screen for CalWORKs Diversion Services and to refer families to an established contact person in CalWORKs. CalWORKs Diversion provides services to anyone potentially eligible for CalWORKs to prevent them from entering CalWORKs. If a family enters CalWORKs within six months, the diversion payment is recouped from their grant. If the program participant and their family do not enter CalWORKs within six months of receiving Diversion, the Diversion grant is forgiven. Diversion services can include car repairs, child care, provision of tools needed for employment, and other services to assist in obtaining or retaining employment. As part of Diversion, the family is also screened for eligibility for Food Stamps and Medi-Cal. Example of Diversion Services after a Domestic Violence Episode or Report After a domestic violence report is made to the CPS Hotline, the CalWORKs worker and CWS Emergency Response worker coordinate with a domestic violence service provider to develop a plan to ensure safety for the non-offending parent and children. The plan uses resources from both programs. If the non-offending parent has left the abuser, services are geared toward getting employment for the newly separated parent in order to prevent a need for public assistance. The non-offending parent is potentially eligible for CalWORKs services, including housing, transportation, employment assistance, and child care. enters the CWS system may or may not need services from CalWORKs. At the same time, given the initial successes of CalWORKs in assisting people to gain employment, it is generally felt that many of the families who are still in CalWORKs may face multiple issues and are more likely to be in need of intensive services. What new protocols and training will be necessary to implement the new intake and screening procedures? Implementing new intake and screening procedures will require development of new protocols and training of staff in the new procedures. See the Organizational Change and Training document for further discussion. Recommendations on Coordinated Case Planning Page 9

10 2. Team Development and Communication Coordination of services requires that there be a team, whether it consists of two workers or more. Many administrative decisions need to be made to select the team members and to ensure their effective communication and their commitment to coordination and to working with families. Table 8 showcases team development and communication arrangements in three counties. Team Development County leaders must make decisions about the composition, roles, and responsibilities of the team that will be involved in coordinated case planning. Who will be the members of the team? Who will be the team leader? What decision-making authority will they have and to whom will they report? Who will select the team members? How will the families/cases be referred or assigned to the team? Will there be community partners on the team? Will they be permanent members or assigned as needed according to a family s need? Will the role of the community partner be purely advisory or will they be involved in policy making or direct service? Will the community partners address issues in both program areas? For example, will the community mental health provider address employment barriers and child welfare issues? Will there be a primary case manager for the family to ensure follow-through with the plan? If so, will that be predetermined, e.g., always the TANF worker or always the CWS worker? Or will that be decided on a case-by-case basis using certain criteria? In developing a team, the Work Group advises that county leaders carefully consider the roles of each member. Some members of the team, like CWS social workers, will have legal mandates and responsibilities not shared by other team members. Involving community partners can strengthen the process, but this should be done with awareness that the activities of community partners cannot be coordinated to the same degree as those of county employees. The role of community partners needs Table 8 Team Development and Communication Yolo County has a multidisciplinary team which includes 7 CWS Social Workers, 1 CalWORKs Employment Services Social Worker, 1 CalWORKs Public Assistance Specialist, and 1 Medi-Cal/Food Stamp Public Assistance Specialist. Staff are supervised by their respective program supervisors and the team is supervised by the on-site Child Welfare Supervisor. The CWS Social Worker acts as a lead case manager. Also co-located with the team are clinicians from Alcohol, Drug and Mental Health Services and nurses from the Health Department. Orange County has a Mutual Clients Project which involves all CalWORKs district offices and all CWS court and non-court services units. Staff are supervised by their respective CalWORKs and CWS supervisors. All referrals for services are done through the CalWORKs case manager. Mutual clients are considered agency clients so information can be shared. Kern County has court-ordered family maintenance cases handled by teams of CWS, Eligibility, and Employment Social Workers. The initial home visit for Family Maintenance is by all three CWS and CalWORKs workers. Staff are supervised by their respective CalWORKs and CWS Supervisors. CWS is lead for planning services. After CWS issues are resolved, the case can stay in CalWORKs. Information is shared freely under the agency s one department, one vision philosophy. Recommendations on Coordinated Case Planning Page 10

11 to be thought through carefully to ensure that their time and expertise is wisely used and that commitments made to them can be met. For example, in choosing community partners, county leaders might consider how child care providers can be a resource both to identify risk and to provide support for parents. Domestic violence counselors can offer similar benefits. It may be that the county decides to begin case coordination with CalWORKs and Child Welfare Services and later expands to include other programs and service Finally, while the focus of the CalWORKs/Child Welfare Partnership Project is on the coordination providers to offer more of these two programs, county leaders should integrated planning for consider whether or not it makes sense for the county to involve representatives from other clients and their families. governmental agencies on their teams. For example, representatives providing services relating to substance abuse, mental health, and public health may also be developing case plans with requirements or deadlines for clients and their families, so coordination with these providers can improve services. It may be that the county decides to begin case coordination with CalWORKs and Child Welfare Services and later expands to include other programs and service providers to offer more integrated planning for clients and their families. Team Communication There must be a system to ensure that workers from the coordinating programs communicate with each other about common clients, the families needs, and the services available to help them. How will team members communicate with each other? In-person meetings? Phone conversations? ? How frequently? Daily, weekly? As needed? How will the team make decisions? How will differences or disputes be resolved? Where will the team members be located? Co-location of staff and services is not a requirement for coordinated case planning. What is required is a consistent method of sharing client information. Counties can consider co-location an opportunity for workers from different programs to develop informal relationships, learn about and understand the resources they each have to offer, and more easily coordinate services for the families. How can confidentiality requirements support coordinated case planning? In multi-program cases, responsible sharing of client information is often necessary for program administration and the achievement of case outcomes that can benefit families. In some counties, different confidentiality requirements in CalWORKs and CWS make the sharing of information and coordinated case planning difficult. Through their research, however, the Work Group has concluded that it is entirely possible and legal to establish client confidentiality requirements that can both safeguard a family s expectations of privacy and allow for sharing of client information between CalWORKs and CWS. The Work Group strongly recommends that all California counties adopt procedures that allow respectful sharing of client information between programs. See the recommendations on confidentiality from the Data Systems and Confidentiality Work Group. Recommendations on Coordinated Case Planning Page 11

12 3. Client and Family Assessment In most counties, it is likely that CalWORKs and CWS will each conduct its own separate assessment. In order to enhance the likelihood that the family can meet the requirements of both programs, there must be a system for coordinating the information from the two assessments and developing either two coordinated service plans or one unified plan. Some of the key decisions that need to be made about coordinating the assessments from the two programs include: Table 9 Unified Assessment Tool Not Available at This Time Who will determine when a coordinated assessment might be needed? How will the assessments be conducted? Will caseworkers assess separately, in serial fashion, and then share information? Or will they conduct a joint meeting or home visit? What can be done to ensure adequate assessment of clients from diverse populations in the county? For instance, what is the availability of bilingual services? At what point are assessments shared? Who receives and/or has access to the assessment information? What are the indicators that trigger a family assessment? Can clients or their families be assessed for voluntary prevention services, and if so, when does this happen? For example, some CalWORKs families might benefit from services traditionally offered in CWS (parenting skills, etc.) and many CWS families might benefit from public assistance and employment services. Other examples include assessing families with unsubstantiated child welfare cases for prevention and employment services or assessing CalWORKs cases with domestic violence concerns for child welfare services. What kind of training is required for workers involved in the assessment process? In interviews with leaders and researchers in California, Work Group members were not able to identify a comprehensive assessment tool that had been developed or was being used for families in both CalWORKs and CWS. Counties in North Carolina participating in that state s TANF/Child Welfare Collaborative have, through an intensive and time-consuming process, developed comprehensive, strengths-based assessment tools. Some counties are now testing versions of such tools and working to define how the tools can best be blended with existing agency approaches. A committee comprised of representatives of nine counties and the State Division of Social Services meets regularly to share work accomplished and lessons learned in this area. Consequently, the Work Group, after considerable discussion about a comprehensive assessment tool, concluded that it may take more effort to develop such a tool than it is worth. The Work Group recommends not spending time trying to develop the perfect assessment tool, but rather focusing attention more on sharing assessments, using computers to make information available to workers and partner agencies, having regular contact on client and family status, and making the elements of the service plan understandable to all involved. If an assessment tool is essential for shared work, limit it to a core set of critical questions. Recommendations on Coordinated Case Planning Page 12

13 4. Development of a Coordinated Service Plan A primary objective of coordinating case planning is to link services for clients and their families, so that they can avoid conflicting goals and timelines and so that they are more likely to achieve positive outcomes. Coordinated service plans can be developed using different approaches (see Table 10), which gives counties options to tailor the process to their own objectives and resources. The Work Group offers the following guidelines as counties choose an approach to developing a coordinated service plan: Staffing Staff needs specific training in developing a coordinated case plan and group decision making. Management needs to provide clear lines of responsibility, authority, and supervision. The plan must clearly state who is responsible for each activity in the plan, including specifying who will resolve staff disputes. Accountability is critical to ensure that the plans are successful. Management shouldn t assume that co-location means that staff are coordinating services. Co-location can assist with coordination, but communication protocols are necessary. Staff needs training on how to engage families in the process. Table 10 Approaches to Developing a Coordinated Service Plan One comprehensive service plan is developed in a joint meeting and used by all case managers and providers. Separate service plans are developed for each program, and a team meeting is held afterwards to coordinate plan goals, services and timelines based on each family s priorities. A separate service plan is developed in each program, and programs only consult with each other as needed to evaluate a family s progress toward goals and to resolve conflicts. Clear guidelines need to be established on confidentiality to allow smooth transfer of client information and to avoid having confidentiality become a reason not to coordinate services. Staff will have valuable feedback on how to improve the coordinated case planning process; there should be opportunities offered for staff to provide this feedback in a setting where it can be thoroughly discussed. County leaders need to determine which agencies will be involved in developing a coordinated plan and, possibly, consider coordinating with plans developed in other systems, such as juvenile justice, mental health, and education. Consider how paraprofessionals, parents, teens, persons in recovery, and others might assist as service staff or in a liaison role with clients, families, and the community. Family Involvement Families need to participate in developing the coordinated case plan, and case plan requirements need to be identified and prioritized for and with each family. Steps should be taken to prepare families for participating in meetings, empowering the families to speak for themselves. While families should be included in case plan meetings, they should not be present when the different departments are deciding who is going to be the lead or what department will provide or pay for a service. Family participation in prevention services should not be perceived by parents to be a requirement to qualify for CalWORKs. Recommendations on Coordinated Case Planning Page 13

14 Other Considerations Consider how services can be designed to address the needs of the family and of the children, regardless of how they enter our system or where they are assessed. What are the least intrusive services that can be effective in assisting the family? Domestic violence is a critical issue and not always fully considered until a crisis occurs. Consider how all coordinated case plans can include provisions to ensure the safety of clients, family members, and workers. In domestic violence cases where restraining orders exist, separate plans need to be developed for victims and batterers. Maintain a focus on designing a process that results in good outcomes for families and guard against process for process sake. Consider adopting a county policy that requires consideration of the CWS plan activities as part of the CalWORKs plan requirements and thus unifies the two plans. Table 11 One Way to Achieve a Unified Plan: T he CWS Plan Meets the Requirements of the CalWORKs Plan When clients and their families are involved in both CWS and CalWORKs, they frequently have competing or conflicting plans. Some counties have established policies that allow the CWS plan activities to meet the requirements of the CalWORKs plan. In this way, families are provided the opportunity to work to keep their family intact and focus first on services to help them address issues of child safety or neglect. After CWS issues are resolved, the family may continue in CalWORKs. The Orange County Social Services Agency has established policies and procedures to implement a unified plan. See Appendix C. If the CWS service plan includes poverty issues, there will be a better fit with the CalWORKs plan, and the plan can be identified as meeting the requirements for both programs (see Table 11). County Examples In their research into how counties develop coordinated service plans, the Work Group identified valuable examples from counties. A comprehensive approach is used in Santa Clara County which integrates plans when a client has open cases in both CWS and CalWORKs (see Appendix A). Appendix B provides a flow chart that shows how Santa Clara County develops coordinated service plans to link a CWS client to CalWORKs. Appendix C excerpts policies and procedures used at the Orange County Social Services Agency. To coordinate service delivery, these policies and procedures guide staff in assisting clients who have both an open or pending CalWORKs case or a CalWORKs retention case and an open CWS case. Appendix D presents policies and procedures from Cuyahoga County, Ohio, that guide planning for clients in both TANF and CWS, as well as for TANF clients who have reached time limits or have been sanctioned. Finally, Table 12 presents two descriptions of case plans for the same family, a composite of actual circumstances for families in CalWORKs and CWS. These descriptions illustrate how uncoordinated and coordinated case plans can impact family life in dramatically different ways. The descriptions also showcase strategies to coordinate plans, approaches currently in use in Orange County. Recommendations on Coordinated Case Planning Page 14

15 Table 12 Comparing Uncoordinated and Coordinated Plans: Impacts on Family Lives Below are two descriptions of case plans for the same family, a composite of actual circumstances for families in CalWORKs and CWS. These descriptions illustrate how uncoordinated and coordinated case plans can impact family life in dramatically different ways. The descriptions also showcase strategies to coordinate plans, approaches currently in use in Orange County.* An Uncoordinated CalWORKs and CWS Plan CalWORKs Plan Mom and Dad are on CalWORKs. The CalWORKs worker did not inquire whether they are also receiving CWS services, and the clients did not mention it. Dad is participating 35 hours per week in approved CalWORKs Welfare-to-Work activity. His CalWORKs Welfare-to-Work plan includes 32 hours of vocational training at the community college in a four-month intensive training program. Dad will have a refrigeration repair certification at the end of the class. Dad must also receive three hours a week of Behavioral Health Services. No child care is provided because Mom is staying home with the children. CWS Plan The CWS worker did not inquire whether the family is on a CalWORKs Welfare-to-Work plan, and the clients did not mention it. Child Welfare Services activities require parenting education classes and counseling three times a week for three months for both parents. Mom has mandated drug testing weekly and is required to participate in substance abuse treatment. In addition to a weekly therapist session, she has to attend a one-hour group session at least four times a week. Dad must attend Al-Anon once weekly. A Coordinated CalWORKs /CWS Plan Agency identifies clients who are in both programs and informs both the CalWORKs and CWS workers that Mom and Dad are in CalWORKs and CWS. For CalWORKs, Dad is participating 35 hours per week in an approved Welfare-to-Work activity. Dad's CalWORKs plan includes CWS activities: parenting classes and Al-Anon totaling ten hours per week and three hours coordinated with Behavioral Health Services. The CWS worker uses participation in CalWORKs Behavioral Health Services to meet Mom and Dad's counseling and parent education requirements. The CWS worker also uses the CalWORKs requirement of 20 hours of vocational training, which will be completed in six months, to demonstrate Dad's cooperation and efforts towards stability. Child care for the children will be paid through CalWORKs while Mom attends drug counseling and testing as required by the CWS case plan. The CWS and CalWORKs workers jointly address the appropriateness of the child care provider and Trustline requirements. Transportation is paid through CalWORKs for parents to get to various CWS and CalWORKs activities. * Composite case plan descriptions provided by Ray Gallagher, Program Manager, Children and Family Services, and Pam Boozan, Program Manager, CalWORKs, both from the Orange County Social Services Agency. Recommendations on Coordinated Case Planning Page 15

16 5. Case Management and Case Resolution The Work Group offers the following guidelines for case management and resolution for coordinated service delivery, guidelines that emphasize a family focus. A system must be in place to ensure that Case Management communication takes place A system must be in place to ensure that communication takes place between the between the CalWORKs CalWORKs and CWS workers. The family must have clear and definite and Child Welfare Services information throughout the process about workers. expectations and about what will happen if the family fails to comply with or meet the conditions of the plan. This information needs to be stated at the beginning and throughout the life of the plan. The family must have a primary contact person to call. Services must be specific to the identified problem, not generalized. Goals and outcomes for the family's participation and progress must be measurable. There must be a timeline and a time limit. Workers should not ask families to accomplish the unrealistic feat of completing distinct program expectations simultaneously. There must be clear criteria that trigger case review. Consider length of time in the program, a request from a caseworker, likelihood of sanctions, and lack of school attendance by children. Case review, which can be a formal process, offers the opportunity to reassess what changes in services might be needed by families to strengthen the service plan(s). Case Resolution Protocols must be clear on who has final authority to close a case and on the process to reach the final decision. Protocols and processes must be clear on how to transition case management and service delivery: To one program in cases when dual involvement is no longer necessary or beneficial. To support systems outside of public social services. Decisions need to be made about the degree to which the family will be involved in discussions about case closure. When cases close, families should be offered information and contacts on transition services. Because coordinated case planning can offer a higher and more tailored level of service, the Work Group considers a county s commitment to coordinated case planning an indicator of their commitment to develop meaningful plans for families, as opposed to boilerplate plans that are similar for every family. Work Group members also believe that coordinated case planning offers a special opportunity for counties to provide after-care services to families once they have accomplished their original service plan objectives. For example, a family can have their case closed in CWS, but remain eligible for and possibly obtain CalWORKs services to further stabilize the family situation. This avoids setting up a family to fail by not providing follow-up services to assist with remaining issues (even though CWS intervention is no longer needed). After-care services can also reduce recidivism. Recommendations on Coordinated Case Planning Page 16

17 ADMINISTRATIVE DECISIONS RELATED TO COORDINATED CASE PLANNING In addition to the decisions that county leaders must make about the five components of coordinated case planning, there are a number of overarching administrative decisions that need to be made: Policy, Procedures, and Forms To institutionalize coordinated case planning and to convey that it is a permanent reform in service delivery, administrators will need to develop formal policies and procedures, as well as analyze how intake, assessment, and other forms need to be revised. Performance Evaluations Performance evaluations need to hold staff at all levels workers, supervisors, managers, and administrators accountable for the coordination of services between the two programs. Goals are shared, which means that each worker is, in part, evaluated on the success of the team. Program Evaluations Coordinated case planning programs need to be evaluated with assessments from staff, managers, clients and their families, and other partners. Funding Coordinated Services The Work Group recommends that the state and counties take action to assist service delivery workers in their ability to focus on providing families with needed services which are within the scope of the service plan, rather than on trying to determine which funding stream to bill. The Work Group recognizes that caseworkers must be mindful of budgeted resources, but it should be the responsibility of fiscal and contract staff, not caseworkers, to make decisions about funding stream issues. Ongoing Funding for Family Services Counties need to designate appropriate funding to meet families needs and to implement service plans. Currently, some counties use TANF incentive dollars to provide services, such as parenting education (previously available only through CWS) to TANF-eligible families. Title IV-E can also be used in a variety of ways to support coordinated case planning, prevention services, and training activities (see Table 13). Funding for Training The Work Group recognizes that there is not one funding stream for developing curricula and training staff from CalWORKs and CWS. However, a careful understanding of the flexibility afforded under Title IV-E funds will help county directors maximize their training dollars. Title IV-E training funds can be used to develop, coordinate, and present any training for any public agency staff as long as that training assists in the provision of child welfare services. For example, staff from any county department can attend a basic orientation on child welfare, with the curriculum development and presentation being charged to Title IV-E training codes. Staff attending training would time study to the appropriate training code for their program. Another example is also valuable. CWS staff could attend a CalWORKs training on CalWORKs and charge their staff time to Title IV-E, as long as the purpose of the training is to train CWS workers to better serve their child welfare clients through CalWORKs services and resources and/or to implement or improve coordinated services for mutual clients. In summary, non-cws staff cannot time study against Title IV-E for attending a Title IV-E training, but there are no restrictions on them attending a presentation developed or supported with Title IV-E funds. Nor are there restrictions on using Title IV-E funds to develop curricula or present curricula to non-cws staff, as long as the intention of the curricula is to support child welfare services. Recommendations on Coordinated Case Planning Page 17

18 Table 13 Allowable Uses of Title IV-E* Title IV-E can be a source of reimbursement for activities defined in the recommendations on coordinated case planning, including for planning and coordination activities, for prevention services, and for training. To the extent that planning and coordination activities assist in the more efficient administration of the state s Title IV-E plan, they can be claimed by counties as Title IV-E administrative costs. If a county wishes to develop and implement a coordinated case planning model, the county may claim the costs associated with developing policies and procedures and implementing the project as start-up non-recurring costs (including those costs incurred by other public agencies). Allowable costs include salaries and benefits, equipment, supplies, purchase of vehicles, furniture, moving costs, and electronic data-processing equipment. The costs can be claimed as direct start-up in accordance with claim instructions outlined in County Fiscal Letter No. 97/98-26, which is available on the CDSS web site at under CDSS Letters and Notices. Specifically, for those children the county reasonably views as foster care candidates, Title IV-E allows reimbursement for pre-placement prevention activities that include completing an assessment, developing a case plan, and referral to services. Reimbursement does not cover an investigation. To meet federal requirements for documenting a child's candidacy for foster care, an individual case plan must verify that without the services outlined in the plan, the child would be placed in out-of-home care. For multiagency teams completing coordinated case planning services, the County Welfare Department must review the cases to validate the child's risk. All costs must be discounted using nonfederal caseload counts. In addition, Title IV-E training funds can be used to develop, coordinate, and present any training for any public agency staff as long as that training assists in the provision of child welfare services. * Reviewed by CDSS Fiscal Policy Bureau, May Recommendations on Coordinated Case Planning Page 18

19 Master Contract The Work Group recommends that CalWORKs and CWS have a single master contract with partnering service organizations. For example, there could be one service contract with a mental health agency for both CalWORKs and CWS clients. This ensures that the partnering organization will appropriately prioritize the delivery of services to clients and that it has adequate capacity to address the clients total needs. A single master contract may also save time and effort spent in contract administration for both programs. Training for Delivery of Coordinated Case Planning Services The Work Group recommends that a strengths-based approach for families be a theme interwoven throughout all training. The Work Group recommends covering, at minimum, the following training components for staff involved in coordinated case planning: Basic orientation of both CWS and TANF an overview of the other program, including goals, objectives, legislative mandates and regulations, staff responsibilities, job descriptions, and daily experiences Organizational culture How to Build Bridges? Client identification and referral Team development and communication Client and family assessment Development of a coordinated service plan Case management and case resolution Family group decision making Conflict resolution Meeting facilitation Confidentiality END NOTE This document provides county leaders both a conceptual framework and practical guidelines to implement coordinated case planning to achieve family-focused and strengths-based coordination of CalWORKs and CWS services. Early in their research process, the Coordinated Case Planning Work Group determined that while coordinated case planning is a widely known and supported concept, there is no commonly accepted definition or model of coordinated case planning. When people discuss coordinated case planning, they often refer to different organizational arrangements. To assist in establishing common definitions and vernacular, the Work Group offers four different models of coordinated case planning, arrayed along a continuum. The Work Group also identifies five basic components that are used to design most, if not all, coordinated case planning processes. County leaders are offered guidelines to determine how to configure each component to implement coordinated case planning in their counties. Finally, the Work Group offers administrative recommendations, including recommendations relating to funding and contracting, to help county leaders implement and support coordinated case planning. Recommendations on Coordinated Case Planning Page 19

20 APPENDIX A County of Santa Clara CalWORKs-DFCS Collaboration Effort On Crossover Active/Open Cases Service Delivery Model In Development Active/Open CalWORKs and CWS Case Appears on Crossover/Joint Caseload List generated monthly. Case Assigned Employment Technician ET Lead receives Crossover/Joint Caseload list and reviews with Supervisor. Case is assigned to ET if CWS case will be open 30 days or more. Employment Services Orientation Employment Technician (ET) conducts CalWORKs Employment Services 1:1 Orientation, if necessary. First Staff Meeting to Coordinate Case Assigned ET and CWS Social Worker meet to discuss case, case status, court plan, and potential needs, and schedule a service coordination meeting that includes client and all of the service providers. Staff and Family Meet on Service Plan ET convenes service coordination meeting (within 2 weeks) with assistance from CWS SW and, with input and buy-in from client, identifies strengths, barriers, needs and concerns; identifies activities and hours to be integrated into plan; and identifies and secures services to support plan; secures client s agreement to the plan; and reviews expectations and verification requirements and next steps with client. Need for Employment Services Assessed/Appropriate Referrals Made Employment Counselor conducts group or individual testing, discusses results, and develops plan to address barriers with client, secures client s agreement, leverages support services and refers client to CalWORKs Social Worker, if appropriate. Staff Coordinate Case Plan Monitoring and Modifications CWS SW and ET monitor Crossover/Joint case plan for progress and compliance to agreements. Necessary modifications to plan are facilitated jointly with ET and CWS SW always securing involvement of the client. Case Resolution and After-Care CWS Case Closes. CalWORKs case remains open (up to one year) with existing ET and a CWS who is assigned to provide after care services in order to prevent family from re-entering CWS Child Welfare System. Information provided courtesy of the Santa Clara Social Services Agency. Recommendations on Coordinated Case Planning Page 20