As a result of AHS reorganization inquiry phase, “effective service coordination” was identified as a key theme. Service coordination is closely linked to the other themes:

 

 

Prior to implementation of AHS reorganization, a statewide task force was convened to outline what service coordination might look like in the new organization.

 

This document brings together content from the state task force’s work as well as service coordination experience through the AHS field director. Further, 20 plus years of experience by the field director in a prior management role developing and maintaining systems to encourage and support teamwork models and individualized service planning efforts are also built into this document.

 

 

Our service culture across the Agency of Human Services will assure that individuals and families are respected and their strengths are valued. Interventions and services will be delivered in a way to avoid crises.

 

The service culture will be one in which “teamwork” is the norm. If a family or individual is involved with more than one case management service, the expectation across the agency is that plans will be unified, integrated, and consistent, and will have a set of common goals, respecting the individual departmental goals. Families and individuals deserve to know what’s expected of them and we, as AHS staff, have an obligation to coordinate our multiple department and division expectations.

 

The goal is that each family or individual that meets the criteria will have a service coordinator who will provide leadership for the team assuring that plans are integrated and that there is excellent communication amongst the service providers and the family or individual. 

 

 

Service coordination is a systematic process for coordinating informal supports and formal services across agencies, departments, and the community. The goal of service coordination is an integrated delivery system that is responsive to the needs of the individuals and families served by the Agency of Human Services and the community.

 

 

·        Assessment

·        Planning

·        Implementation

·        Coordination

·        Monitoring

·        Evaluation

 

 

·        The needs of the entire family or individual are addressed through service coordination

·        The individual or family’s involvement in the service planning process is central - their voice is critical to the development of a coordinated plan

·        The plan builds on the strengths and abilities of the individual or family

·        Service coordination decisions are tailored to the uniqueness of the individual or family

 

Individuals and families should be referred for service coordination when the following conditions exist (the intent is to keep referral criteria simple and not base it on a specific diagnosis or multiple failures):

 

·        multiple departments or organizations are involved or the complexities of the individual and family suggest that multiple agencies should be involved

·        the individual organizational service goals run contrary to one another creating confusion or conflict for the family or individual

 

By design, service coordination is not intended to receive referrals solely based on a crisis and it is not intended to be an emergency response. Rather it is designed to be a deliberative planning process that can build in crisis or safety plans.

 

 

 

 

 

AHS staff, during their intake or initial application process, should ask about the involvement by a family/household or individual with other services. If the person is involved with multiple state services, there is an expectation that those AHS departments/divisions will coordinate their plans. Common sense dictates that member departments of the Agency of Human Services should not have individual plans that run contrary to other AHS departments/divisions

 

A referral to the AHS service coordinator should be considered when such conditions exist. The AHS service coordinator can convene a team meeting and assist in the development of a coordinated plan.

 

The service coordinator will respond to the referral request within 3 business days. The referring staff member will provide the following information which will constitute a referral:

 

·        Reason for the referral

·        List of people and organizations involved with the family or individual

·        Description of prior efforts to support the family or individual

·        Current department goal for family or individual

 

The service coordinator will:

 

·        Have access to AHS records using a standard release

·        Convene the team

·        Facilitate team meetings

·        Use the individual service planning model during team meetings,

·        Develop a list of needs and strengths, paying special attention to critical unmet needs, such as housing

·        Develop a list of tasks team members will follow-up on prior to the next team meeting

·        Set the date/time and agenda for further meetings

 

Once a team is convened and policy or funding issues are identified as significant roadblocks to implementing the coordinated plan, the Field Director will be consulted. The Field Director will refer such matters, if they cannot be resolved locally, to the New Agency Team or other state or local level venue, such as the Local Interagency Team or Child Protection Team, for consideration.

 

 

 

 

 

 

 

·        assist in the development of a model approach for service coordination for use throughout the Agency of Human Services and amongst its partners

·        assist in the development of a protocol for providing service coordination including referral process, service expectations, length of service involvement, among others

·        assist in the development of a training program to spread the skills of service coordination throughout the Agency of Human Services with a goal of building service coordination capacity

·        provide service coordination to referred families and individuals

 

 

 

·        a model approach exists and is available throughout the Agency of Human Services and amongst its partners

·        a protocol for service coordination referral exists and AHS staff can articulate the purpose and outcomes expected from service coordination

·        AHS staff are trained in and are implementing the service coordination model

·        an increase in consumer functioning is reported