I. INTRODUCTION Child and Family Team Facilitator Program (CFTF Program) CFTF Program CFTF Program CFTF Program

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1 I. INTRODUCTION A. The Washington County Community Partnership for Children & Families (WCCP) is seeking Combined Qualification and Experience (Q&E) Submittals and Technical Proposals, as well as Price Proposals from qualified organizations to provide and implement a Child and Family Team Facilitator Program (CFTF Program) in Washington County. The CFTF Program will provide care coordination services to children, youth and families using a Wraparound service delivery model. During the course of the contract, the CFTF Program may be designated as a Care Management Entity (CME), responsible for developing a network of providers and delivering care coordination services using the Wraparound process to families in Washington County. The purpose of the service to be provided, and of this agreement, is to fulfill the requirements contained in the WCCP s Community Partnership Agreement (dated June 29, 2007) with the Governor s Office for Children (GOC). B. Through its work with the local System of Care Planning Team, the WCCP has designed a local System of Care (SOC) for children and youth with intensive needs in response to House Bill 1386 (2002). This SOC was created to ensure that there is a full continuum of care that is child-centered, family-driven, culturally and linguistically competent, and evidence-based for children, birth through 21 years old, who possess intensive behavioral, educational, developmental, emotional, physical, chronic physical and/or mental health needs. To date, several components of this SOC have been established, particularly around the Local Access Mechanism. a. The WCCP contracted with the Frederick County Mental Health Association (MHA) for Washington County s participation in the pilot and to begin building the infrastructure to 1) maintain an updated resource database and 2) screen and identify children and youth with intensive needs. b. Through a partnership between Washington, Frederick, Garrett and Allegany Counties, additional funding has been received from the GOC to continue the work with MHA and to implement a systems navigation strategy. Washington and Allegany Counties have chosen to use legacy family members to serve as the navigators, known as family navigators. The WCCP and Allegany County have entered into a contract with the Maryland Coalition of Families for Children s Mental Health to provide navigation services. This strategy is known operationally as The Family Network. c. The CFTF Program is a step toward developing the final component of the SOC, which is a CME. The CFTF Program will work collaboratively with the Local Coordinating Council (LCC), public child-serving agencies, community-based providers, The Family Network, and the Department of Social Services voluntary placement coordinator to serve children and youth whose needs have become intensive. C. All qualified providers are hereby invited to make submittals regarding their qualifications and experience with an accompanying Technical Proposal. In addition, they are to submit Price Proposals at this time. Program monitoring will include administration, data collection, and fiscal management, which must be described.

2 D. The vendor for the CFTF Program shall not be 1) a public agency represented on the LCC or 2) any other direct service provider from whom the family and youth could potentially access services as part of the Plan of Care. An agency with the CFTF Program and direct service programs under their umbrella that serve the target population of the RFP are inherently vulnerable to a conflict of interest. E. The Contractor agrees to observe all state and federal laws and regulations as to disclosure of information and records on children, youth and families being served. F. The project will meet all provisions effective at the time the proposal is awarded. The following Scope of Work represents, but will not limit, the extent of services required. II. SCOPE OF WORK Focus Area for Child and Family Team Facilitator Program: A. Population Served. 1.The primary target population for the CFTF Program are Community Services Initiative (CSI) eligible children and youth who are returning or being diverted from residential treatment center (RTC) level placements. To be determined eligible for (CSI), the child must have an open case and currently be receiving services from a lead service agency. Additionally, there must be a determination that the child s needs could be met without CSI funding after a period of two (2) years. 2.The secondary target population for the CFTF Program are Rehab Option-funding eligible children and youth with a mental illness or developmental disability, not in State custody, regardless of whether they are eligible for the Maryland Medical Assistance Program. The child is either in an out-of-home (OOH) placement and has been recommended for discharge but the family is unwilling or unable to have the child return home OR the child remains in the home but is at risk of OOH placement because the family is unable to provide appropriate care without additional services. Additionally, there must be a determination that the child s needs could be met without Rehab Option funding after a period of two (2) years. Note: Eligibility criteria, order of prioritization, funding limits, etc. for use of CSI or Rehab Option funding are detailed in Attachment No. 1. There is no legal entitlement to CSI or Rehab Option funded services, and Local Management Boards (LMB) have the discretion to determine the most effective use of such funds provided by the Children s Cabinet. An LMB s decision whether to provide services to an individual child is subject to eligibility requirements and may depend upon the availability of State funds, as well as such factors as the total cost of the services needed by the child, the availability of qualified providers and other relevant consideration. 3. The tertiary target population for the CFTF Program are children and youth, birth through 21 years old, who are 1) moderately at-risk for OOH placement, or

3 2) imminently at-risk for OOH placement who are ineligible for Interagency Family Preservation (IFP) services or do not wish to engage in IFP services. 4. If, during the course of the Contract, the CFTF Program is designated as a CME, additional children and youth may be served under the 1915(c) Psychiatric Residential Treatment Facility (PRTF) Demonstration Grant Waiver. The waiver allows for federal matching dollars, which results in the maximization of state funds. In order to participate in the waiver, children and youth must receive a Certificate of Need (CON) indicating Medical Necessity for RTC level of care AND be safely and appropriately served in the community with waiver supports. B. Program Structure. 1. Utilizing the 10 essential elements of the Wraparound process articulated by the National Wraparound Initiative, the CFTF Program will be responsible for developing and coordinating family-driven teams to meet the individualized needs of targeted children and youth. 2. The Care Coordinator will partner collaboratively with the family navigators so that families are able to receive peer-to-peer support throughout the Wraparound process. 3. Membership on the Child and Family Team (CFT) will be comprised of formal and natural supports, including the youth, caregivers, Care Coordinator, family navigator, agencies with mandated involvement with the child and family and any other agency the family requests to be involved. 4. The CFTF Program s Care Coordinator will work collaboratively with the LCC, public child-serving agencies, community-based providers, The Family Network, and the Department of Social Services voluntary placement coordinator to identify children and youth and their families who could best be served by the CFT process. However, the decision to engage in the CFT process ultimately rests with the family. 5. Referrals to the CFTF Program will come from public child-serving agencies, community-based providers, The Family Network, and self-referral. C. Staffing Requirements. 1. The Care Coordinator must possess a minimum of a Bachelor s Degree in Social Work or other related Human Services field, such as social work, counseling, psychology, psychiatric nursing, criminal justice or special education, and must have a valid driver s license and pass criminal and child protective services background checks. 2. The Care Coordinator must receive supervision from an individual with a Master's degree in a relevant discipline, such as social work, counseling, psychology, psychiatric nursing, criminal justice or special education, with a minimum of two

4 years post Master's related supervisory experience in child welfare, children's mental health, juvenile justice, special education or a related public sector human services or behavioral health field working with at risk children and families. D. Service Delivery Model 1. The Care Coordinator will contact the family within 72 hours of receipt of the referral. 2. The Care Coordinator will link the family with a family navigator and, when possible, will arrange a first meeting with the family to include the family navigator. The first face-to-face meeting will occur within one week of contacting the family. At the first meeting, the Care Coordinator, youth, family, and family navigator, will: a. Develop an initial plan of care and crisis plan; and, b. Identify a roster of individuals to participate on the CFT. 3. Following the development of the roster for the CFT, the Care Coordinator will be responsible to convene and facilitate the CFT within two weeks of the initial meeting. 4. The Care Coordinator, with the youth and family and with input from the CFT, will complete the Child and Adolescent Needs and Strengths Assessment (CANS), a comprehensive assessment of the child and family s strengths, concerns, needs and expectations of the process. When reviewed by the CFT during the team meeting, information from the CANS allows the team to develop an individualized Plan of Care (POC) that draws directly from the family s strengths rather than relying on typical categorical services. 5. During the POC development, the Care Coordinator will assist in identifying appropriate providers of services or family-based resources. Upon development of the individualized POC within the first 30 days of enrollment, the Care Coordinator will determine funding eligibility. The funding will come from several sources, but primarily from the CSI and Rehab Option programs. Any contracted service within the plan that is funded with CSI or Rehab Option funds is to be community-based programming that substantially diminishes a child s need for intensive services over a two (2) year period. [Note: If designated as a Care Management Entity, federal monies available through the Maryland 1915(c) Psychiatric Residential Treatment Facility (PRTF) Waiver will also be made available for the purchase of services.] 6. The Care Coordinator will be responsible for meeting with the family face-to-face on at least a weekly basis to provide ongoing assessment and case management services, including related documentation, for services planned and provided during the first month of service provision. Subsequently, the Care Coordinator will be expected to meet with the family face-to-face at least once monthly, but more frequently as articulated in the POC and determined by the needs of the child and family.

5 7. The Care Coordinator will prepare and distribute the POC to each member of the team. In addition to the POC, the Care Coordinator is expected to share with the members of the CFT the collection of documents generated from the CFT process, including, but not limited to, the CANS, meeting summaries, a family crisis plan and, where needed, a safety plan. In addition, the Care Coordinator will provide ongoing support to the team by scheduling at least monthly follow-up reviews, monitoring service delivery, and providing or coordinating trainings related to the team process. The Care Coordinator will monitor progress toward treatment goals. 8. The Care Coordinator will monitor all services authorized for the child or youth s care. Additionally, the Care Coordinator will assure care is delivered in a manner consistent with strength-based, family-centered, and culturally competent values. 9. The Care Coordinator or an established community crisis support service must always be available to the family during times of crisis, regardless of time of day or day of week. 10. The Care Coordinator assures that all necessary data for evaluation is gathered and recorded and will monitor and report on progress and outcomes following the data collection requirements, to include any requirements for data entry in the State of Maryland s Children, Youth and Families Information System (SCYFIS). The Care Coordinator will also maintain an electronic database containing the CANS, POC, meeting notes, and contact information, as well as any other information requested by WCCP. 11. There is no fixed length of time for services provided through the CFT process. However, depending on the funding source utilized for the purchase of services, there may be time limits placed on the purchase of services. Families funded through the CSI or Rehab Option program will be expected to transition by the end of the two-year period. The goal is for families to learn to use the process on their own with informal and community supports while gradually limiting or eliminating the role of the professionals on the team. 12. The Care Coordinator must be able to identify and promote awareness of existing resources within the community and to develop a provider network. The provider network will be varied and be comprised of public child serving agencies, public mental health providers, private agencies, individual practitioners etc. The Care Coordinator must work with the family to identify resources that are covered under the family s insurance or, if the family does not have insurance, that are covered by another resource. Families who are supported by the CSI or Rehab Option program will have access to a flexible pool of funds for service provision. 13. The Care Coordinator will offer consultation and education to all providers regarding the values of the Wraparound model, or will offer referrals to providers to obtain the necessary training and education on the model. The Care Coordinator will work with the LCC in identifying children and youth who meet the eligibility requirements for the CSI, Rehab Option and other available

6 funding, thereby encouraging better utilization of these existing resources in the provision of transitional services for children and youth returning from RTC placements or to divert OOH placements. III. POPULATION SERVED See Section II.A., SCOPE OF WORK, Population Served above. IV. FUNDING INFORMATION A. A total of $60, is available for the administration of the CFTF Program. Applicants may apply for the full award or any part thereof. B. With approval of the LCC/LMB, the awarded vendor will have access to the CSI or Rehab Option funds necessary for the purchase of services specified in the Child and Family Plan developed for each youth. A maximum of $170, is available through the Community Service Initiative (CSI) for FY In addition, an estimated $200,000 will be available in FY 2009 for youth eligible for services under the Rehab Option criteria. C. The BCC reserves the right to renew the Contract for consecutive years through FY Renewal is subject to the availability of funding; modifications to the agreement between the State of Maryland and the BCC relating to the subject matter of this Contract, including, but not limited to, changes to the scope of work through the evolution of a comprehensive System of Care in Washington County; and performance by the Contractor satisfactory to the WCCP, acting on behalf of the BCC. The award for the administration of the CFTF Program will be $60,000 per renewal. In addition, the vendor will have access to the CSI or Rehab Option funds for the purchase of services specified in the Child and Family Plan(s). The funding level for CSI and Rehab Option monies will be determined by the State for each renewal year. D. Purchase of Service funding for all cases will be based on the actual cost of the approved Plan of Care (POC) and funding caps will apply to all cases. Eligibility criteria, order of prioritization, funding limits, etc. for use of CSI or Rehab Option funding are detailed in Attachment No. 1. In addition, the Care Coordinator will have access to flex funds used for expenditures in support of the POC. The availability of flex funds recognizes the need for the Care Coordinator to respond to emergent needs in the ongoing development of an appropriate POC. Flex fund dollars

7 must be used for reasonable and necessary costs. The WCCP has established a written flex fund policy and procedures to ensure that all flex fund expenditures are verifiable. The awarded vendor agrees to abide by these procedures.